The nurse is teaching parents about signs of digoxin (Lanoxin) toxicity. Which is a common sign of digoxin toxicity?

Correct Answer: D

Rationale: Tachycardia, which is an abnormally fast heart rate, is a common sign of digoxin toxicity. Digoxin has a narrow therapeutic index, meaning there is a narrow range between a therapeutic dose and a toxic dose. Symptoms of digoxin toxicity can manifest in the cardiovascular system, such as tachycardia, as well as in other systems of the body. Tachycardia is often seen in cases of digoxin toxicity due to its effects on the heart's electrical conduction system. Other common signs of digoxin toxicity include nausea, vomiting, blurred vision, confusion, and arrhythmias. It is crucial for healthcare providers to monitor patients receiving digoxin closely and educate them about the signs and symptoms of toxicity to prevent adverse outcomes.

Correct Answer: B

Rationale: Recording the color of drainage from each tube and catheter is crucial in the nursing care plan as it provides a means for further comparison and evaluation. Changes in the color of drainage can indicate potential issues such as infection, bleeding, or other complications post-surgery. By monitoring the color of drainage, the nurse can identify any abnormal changes early on and take appropriate actions to address them promptly. This practice helps in assessing the patient's condition and ensuring optimal recovery and healing after the surgery.

Correct Answer: C

Rationale: When a client undergoes treatment for a malignant tumor requiring a urinary diversion procedure, such as a urostomy, it is crucial for nurses to closely monitor for any signs of leakage of urine or stool from the anastomosis site. This is important because it can indicate complications such as infection, poor wound healing, or a breakdown in the surgical site. Detecting and addressing leakage promptly can help prevent further complications and ensure the client's recovery progresses smoothly. While the other options may be important aspects of nursing care, observing for leakage of urine or stool from the anastomosis is the most critical factor in managing clients undergoing treatment for a malignant tumor affecting the urinary system.

Correct Answer: A

Rationale: The patient's presentation suggests that he may be suffering from hypermagnesemia (high magnesium levels) due to excessive ingestion of antacid tablets. Symptoms of hypermagnesemia can include flushing, weakness, and low blood pressure. A serum magnesium level of 11mEq/L is consistent with hypermagnesemia. In this scenario, the other values (2mEq/L, 5mEq/L, 1mEq/L) are unlikely to be the correct magnesium level based on the patient's symptoms and history of antacid ingestion.

Correct Answer: D

Rationale: A client with a history of cardiac dysrhythmias and dehydration requires careful monitoring and management of fluid and electrolyte balance. The most appropriate intervention for rapid correction of dehydration in this scenario is a rapid IV infusion of an electrolyte and glucose solution. This method allows for the quick replacement of fluids and essential electrolytes to restore the client's hydration status efficiently and effectively. Administering fluids orally may not be adequate in this situation, and NG replacement of fluids and nutrients may not be necessary if the client's condition can be managed through IV therapy. Therefore, option D is the most appropriate choice for this client.