The client is on digoxin and has severe digoxin toxicity. What is the nursing priority action?

Correct Answer: B

Rationale: The correct answer is B: Give Digibind as an antidote. Digibind is the specific antidote for severe digoxin toxicity. It works by binding to the excess digoxin in the body, preventing it from exerting its toxic effects. This action helps to rapidly reduce the digoxin levels in the body and reverse the toxicity. Checking the potassium level (choice A) is important but not the priority when the client is experiencing severe toxicity. Changing the dosing of digoxin (choice C) or administering a potassium supplement (choice D) would not address the immediate need to counteract the toxicity. The priority is to administer Digibind to quickly neutralize the digoxin and prevent further harm.

Correct Answer: D

Rationale: The correct answer is D: Decreased blood pressure. Calcium channel blockers inhibit the entry of calcium into cardiac muscle cells, leading to relaxation of blood vessels and decreased cardiac contractility. This results in vasodilation and decreased cardiac output, ultimately lowering blood pressure. Choice A is incorrect as calcium channel blockers typically lead to decreased heart rate due to reduced contractility. Choice B is incorrect as calcium channel blockers do not increase heart rate. Choice C is incorrect as the vasodilatory effect of calcium channel blockers typically leads to decreased blood pressure, not increased.

Correct Answer: A

Rationale: The correct answer is A: Bleeding. Clopidogrel is an antiplatelet medication that can increase the risk of bleeding due to its mechanism of action in preventing blood clot formation. Monitoring for signs of bleeding such as easy bruising, prolonged bleeding from cuts, blood in urine or stool is crucial. Incorrect Choices: B: Hypertension - Clopidogrel does not typically cause hypertension. C: Tachycardia - Clopidogrel does not affect heart rate in a way that would lead to tachycardia. D: Bradycardia - Clopidogrel is not associated with causing bradycardia. In summary, monitoring for bleeding is essential when a client is on clopidogrel due to its antiplatelet effects, while hypertension, tachycardia, and bradycardia are not typically associated adverse effects of this medication.

Correct Answer: A

Rationale: The correct answer is A: Heart rate. Before administering digoxin, it is crucial to check the client's heart rate because digoxin is a medication that affects the heart. Monitoring the heart rate helps assess the client's cardiac function and determines if the medication can be safely given. Checking heart rate ensures that the client is not at risk for potential adverse effects such as bradycardia or arrhythmias. Blood pressure (B), respiratory rate (C), and oxygen saturation (D) are important parameters to monitor but are not as directly related to the action of digoxin on the heart.

Correct Answer: B

Rationale: The correct answer is B: Hold the digoxin and notify the healthcare provider. A potassium level of 3.0 mEq/L can increase the risk of digoxin toxicity as hypokalemia potentiates its effects. Holding the digoxin and informing the healthcare provider allows for further assessment and possible adjustment of the medication regimen. Administering a potassium supplement (A) without adjusting the digoxin dose can still lead to toxicity. Continuing the current digoxin dose (C) without addressing the low potassium level puts the client at risk. Administering Digibind (D) is not necessary at this point as the priority is to address the low potassium level and prevent digoxin toxicity.