Chapter 44- Cardiotonic Agents – Flashcards
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A patient presents to the emergency department with rales, wheezing, and blood-tinged sputum. What does the nurse recognize that these symptoms indicate? A) Cardiomyopathy B) Cardiomegaly C) Valvular heart disease D) Pulmonary edema
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Ans: D Feedback: In left-sided heart failure, the left ventricle pumps inefficiently resulting in a backup of blood into the lungs causing pulmonary vessel congestion and fluid leaks into the alveoli and lung tissue. As more fluid continues to collect in the alveoli, pulmonary edema develops. The patient will present with rales, wheezes, blood-tinged sputum, low oxygenation, and development of a third heart sound. Cardiomyopathy can occur as a result of a viral infection, alcoholism, anabolic steroid abuse, or a collagen disorder. It causes muscle alterations and ineffective contraction and pumping. Cardiomegaly is an enlargement of the heart due to compensatory mechanisms in congestive heart failure (CHF) and leads to ineffective pumping and eventually exacerbated CHF. Valvular heart disease leads to an overload of the ventricles because the valves do not close adequately causing blood to leak backward. This causes muscle stretching and increased demand for oxygen and energy.
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What electrolyte inactivates troponin and allows actin and myosin to form a bridge enabling the muscle fibers to contract? A) Magnesium B) Calcium C) Potassium D) Sodium
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Ans: B Feedback: Calcium must be present to deactivate troponin so that actin and myosin can react to form actinomycin bridges. Potassium, sodium, and magnesium do not affect troponin.
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A 62-year-old African American man diagnosed with congestive heart failure and hypertension has BiDil included in his drug therapy. What nursing assessment finding would indicate the patient is developing a complication from this drug? A) Alopecia B) Photosensitivity C) Anorexia D) Orthostatic hypotension
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Ans: D Feedback: Orthostatic hypotension is an adverse effect of a combination of isosorbide dinitrate and hydralazine called BiDil. This could lead to safety concerns and should be addressed in drug teaching for this patient. Alopecia, photosensitivity, and anorexia are not adverse effects related to this drug.
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The nurse is preparing digoxin for an infant. What is the nurse's priority intervention? A) To perform hand hygiene B) To have another nurse check dosage calculations C) To check the child's apical pulse D) To identify the patient by checking the ID bracelet
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Ans: B Feedback: The margin of safety for the dosage of this drug is very narrow in children. The dosage needs to be very carefully calculated and should be double-checked by another nurse before administration. The other options are important and the nurse should implement all three. However, these actions are of lower priority.
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A patient asks the nurse what cardiac glycosides do to improve his condition. What is the nurse's best response? A) "They decrease the force of myocardial contractions." B) "They help renal blood flow and increase urine output." C) "They increase heart rate." D) "They increase conduction velocity."
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Ans: B Feedback: Cardiac glycosides increase intracellular calcium and allow more calcium to enter myocardial cells. This action causes an increased force of myocardial contraction, an increased cardiac output, and renal perfusion that increases urine output. Cardiac glycosides also serve to slow the heart rate and decrease conduction velocity.
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What is the priority nursing assessment for a patient who is about to begin digoxin therapy? A) Blood glucose levels B) Neurological function C) Kidney function D) Liver function
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Ans: C Feedback: Digoxin is primarily excreted unchanged in the urine, so caution should be exercised if renal impairment is present. Blood glucose levels and neurological and liver function would not be a priority assessment related to digoxin therapy.
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A triage nurse in the emergency department is assessing a 78-year-old man. It is determined that the patient is experiencing severe digoxin toxicity. What drug will the nurse administer immediately? A) Inamrinone (Inocor) B) Digoxin immune Fab (Digibind) C) Verapamil hydrochloride (Calan) D) Quinidine sulfate
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Ans: B Feedback: Digoxin immune Fab is an antigen-binding fragment derived from specific antidigoxin antibodies. The drug is used for the treatment of life-threatening digoxin intoxication when serum levels are greater than 10 ng/mL. Inamrinone is a phosphodiesterase inhibitor that acts as a cardiotonic agent. Verapamil hydrochloride is a calcium channel blocker. Quinidine is an antiarrhythmic agent that when taken with digoxin increases both the therapeutic and toxic effects of digoxin.
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The nurse is providing patient teaching to a patient who has been prescribed digoxin. The patient tells the nurse that she occasionally use herbals and other alternative therapies. What herb would the nurse warn the patient to avoid taking with digoxin? A) Black cohosh B) Ginseng C) Saw palmetto D) Valerian
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Ans: B Feedback: Digoxin toxicity can occur if the drug is taken concurrently with licorice, ginseng, or hawthorn. St. John's wort and psyllium have been shown to decrease the effectiveness of digoxin, so that combination should be avoided. There is no drug-to-drug interaction with black cohosh, saw palmetto, or valerian.
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The nurse administers an IV phosphodiesterase inhibitor. What drug will result in forming a precipitate if given via the same IV line without adequate flushing? A) Albuterol (Proventil) B) Nifedipine (Procardia) C) Furosemide (Lasix) D) Lovastatin (Mevacor)
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Ans: C Feedback: Furosemide, when given with a phosphodiesterase inhibitor, forms precipitates; therefore, this combination should be avoided. Use alternate lines if both of these drugs are being given IV. There are no known drug-to-drug interactions with albuterol, nifedipine, or lovastatin.
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A 6-year-old child weighing 60 pounds has been prescribed oral digoxin (Lanoxin) 30 mcg/kg as a loading dose. How many milligram will she be given? A) 0.218 mg B) 0.418 mg C) 0.618 mg D) 0.818 mg
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Ans: D Feedback: First, using the formula: 2.2 pounds and 60 pounds: multiplied by kg, determine the child's weight in kg (60/2.2 = 27.27 kg). Next, using the formula: amount of drug prescribed times weight in kg, determine the dose in mcg the child should receive (30 multiplied by 27.27 = 0. 818 mcg). Then to determine the amount of mg the child should receive, use the formula: 1 mg: 1,000 mcg = X mg: 818 mcg (818/1,000 = 0.818 mg).
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The nurse assesses the patient before administering digoxin (Lanoxin) and withholds the drug and notifies the physician with what finding? A) Respiratory rate falls below 14 B) History reveals liver failure C) Pulse is 44 beats/min D) Blood pressure is 72/40 mm Hg
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Ans: C Feedback: Monitor apical pulse for 1 full minute before administering the drug to assess for adverse effects. Hold the dose if the pulse is less than 60 beats/min in an adult or less than 90 beats/min in an infant; retake pulse in 1 hour. If pulse remains low, document pulse, withhold the drug, and notify the prescriber.
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When a drug is said to increase the force of contraction of the heart muscle, the nurse appropriately uses what term? A) Positive chronotropic B) Positive inotropic C) Negative inotropic D) Negative dromotropic
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Ans: B Feedback: Sympathetic stimulation causes an increase in heart rate, blood pressure, and rate and depth of respirations, as well as a positive inotropic effect (increased force of contraction) on the heart and an increase in blood volume (through the release of aldosterone). A negative inotropic effect would be one that decreased the force of a contraction. A negative dromotropic effect is one that slows the conduction of the impulse through the atrioventricular node. A positive chronotropic effect is one that increases the heart rate.
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The nurse, caring for a patient who is receiving cardiac glycosides to treat heart failure, will teach the patient to follow what diet? A) High sodium, low potassium, high fat B) Low sodium, low potassium, low fat C) High iron, high calcium, high potassium D) Low sodium, high potassium, low fat
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Ans: D Feedback: Restrict dietary sodium to reduce edema in patients receiving cardiac glycosides. If the patient is hyponatremic or using a potassium-losing diuretic, increase potassium in diet, as well as limit fat intake to reduce weight and atherogenic activity.
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What order for a digitalizing dose of digoxin (Lanoxin) for a 62-year-old man would the nurse consider appropriate and safe to administer? A) 1.25 mg IV now B) 0.75 mg orally now C) 0.25 mg orally every day D) 1 mg intramuscularly every 4 hours × 24 hours
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Ans: B Feedback: Digoxin: Adult: loading dose 0.75 to 1.25 mg orally or 0.125 to 0.25 mg IV, then oral maintenance dose of 0.125 to 0.25 mg/d; decrease dose with renal impairment.
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When administering milrinone (Primacor), the nurse will assess the patient for what common adverse effect? A) Hypoglycemia B) Confusion C) Hypotension D) Seizures
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Ans: C Feedback: The adverse effects most frequently seen with these drugs are ventricular arrhythmias (which can progress to fatal ventricular fibrillation), hypotension, and chest pain. Hypoglycemia, confusion, and seizures are not generally adverse effects of milrinone.
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After administering an IV dose of digoxin, the nurse would expect to see effects within what period of time? A) 30 to 120 minutes B) 5 to 30 minutes C) 1 hour D) 2 hours
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Ans: B Feedback: The drug has a rapid onset of action and rapid absorption (30 to 120 minutes when taken orally, 5 to 30 minutes when given IV).
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The patient taking digoxin (Lanoxin) has developed an infection. What antibiotic can the nurse safely administer to this patient? A) Zithromax B) Erythromycin C) Tetracycline D) Cyclosporine
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Ans: A Feedback: Zithromax may be given without impacting the effects of digoxin. There is a risk of increased therapeutic effects and toxic effects of digoxin if it is taken with verapamil, amiodarone, quinidine, quinine, erythromycin, tetracycline, or cyclosporine. If digoxin is combined with any of these drugs, it may be necessary to decrease the digoxin dose to prevent toxicity. If one of these drugs has been part of a medical regimen with digoxin and is discontinued, the digoxin dose may need to be increased.
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The 96-year-old patient is receiving digoxin (Lanoxin) and furosemide (Lasix). In the morning, the patient complains of a headache and nausea. What will the nurse do first? A) Contact the patient's physician immediately. B) Check her laboratory values and vital signs. C) Administer acetaminophen and Maalox. D) Give her clear liquids and have her lie down.
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Ans: B Feedback: The nurse will check the patient's digoxin level and electrolytes. Assessing vital signs is important because the risk of cardiac arrhythmias could increase due to the patient's receiving furosemide, which is a potassium-losing diuretic. The adverse effects most frequently seen with the cardiac glycosides include headache, weakness, drowsiness, and vision changes (a yellow halo around objects is often reported). Gastrointestinal (GI) upset and anorexia also commonly occur. Only after checking lab values and assessing vital signs might the nurse call the physician. Acetaminophen and Maalox would not be indicated. Having her lie down and restricting her diet to clear liquids would be appropriate but not the first actions.
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The nurse provides teaching about digoxin to the 62-year-old patient. The nurse evaluates patient understanding and determines further teaching is needed when the patient says she will do what? A) "Take the medication daily in the morning." B) "Take her pulse before taking her dose." C) "Weigh herself daily at the same time." D) "Take the medication with a meal."
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Ans: D Feedback: Avoid administering the oral drug with food or antacids to avoid delays in absorption. The other answers are appropriate actions for the patient to take when self-administering digoxin.
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The nurse administers a cardiac glycoside for what therapeutic effect? A) To decrease cardiac output B) To decrease afterload C) To increase ventricular rate D) To increase the force of the contraction of the heart
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Ans: D Feedback: Cardiac glycosides exert a negative cardiotonic and positive inotropic effect. They do not decrease cardiac output, decrease afterload, or increase the ventricular rate of the heart.
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After administering digoxin, what assessment finding would indicate to the nurse that the drug was having the desired effect? A) Increased heart size B) Increased urinary output C) Decreased respiratory rate D) Increased heart rate
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Ans: B Feedback: As cardiac output improves, so does urinary output due to increased renal perfusion. Respiratory rate and heart size would not be impacted by the drug, although ventricular hypertrophy is a common finding in patients with heart failure. Heart rate would decrease as the force of contraction increases, ejecting more blood with each contraction.
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What assessment finding would indicate the patient's left-sided heart failure is worsening? A) Increased jugular venous pressure B) Liver enlargement C) Increased crackles in lung fields D) Increased pulse rate
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Ans: C Feedback: Fluid may accumulate in the lungs due to left sided heart failure. Patients may evidence dyspnea, tachypnea, and orthopnea. Right-sided failure would include increased jugular venous pressure and liver enlargement. Pulse rate could increase or decrease depending on medications administered.
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Which drug is in the class of drugs called human B-type natriuretic peptides? A) Bosentan (Tracleer) B) Milrinone (Primacor) C) Digoxin (Lanoxin) D) Nesiritide (Natrecor)
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Ans: D Feedback: Nesiritide is the only drug currently available in a class of drugs called human B-type natriuretic peptides. Digoxin is a cardiac glycoside. Milrinone is a phosphodiesterase inhibitor. Bosentan is an endothelin receptor antagonist.
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The nurse reviews the patient's lab results and recognizes the patient is at risk for digoxin toxicity due to what electrolyte imbalance? A) Hyperkalemia B) Hypokalemia C) Hypernatremia D) Hyponatremia
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Ans: B Feedback: Electrolyte abnormalities (e.g., increased calcium, decreased potassium, decreased magnesium) could alter the action potential and change the effects of the drug. Hypokalemia and hypomagnesemia increase cardiac excitability and ectopic pacemaker activity leading to dysrhythmias.
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What common action do both cardiac glycosides and phosphodiesterase inhibitors have in common related to therapeutic action? A) Blocking the enzyme phosphodiesterase B) Increasing cellular calcium C) Developing ventricular arrhythmias D) Metabolizing in the liver and excreted in the urine
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Ans: B Feedback: The phosphodiesterase inhibitors block the enzyme phosphodiesterase. This blocking effect leads to an increase in myocardial cell cyclic adenosine monophosphate (cAMP), which increases calcium levels in the cell (Figure 44.4). Increased cellular calcium causes a stronger contraction and prolongs the effects of sympathetic stimulation, which can lead to vasodilation, increased oxygen consumption, and arrhythmias. Digoxin also increases intracellular calcium and allows more calcium to enter myocardial cells during depolarization.
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The nurse evaluates an improvement in the patient's heart failure (HF) status based on what assessment finding? A) Using fewer pillows to sleep B) Increased skin turgor C) Heart rate regular D) Improved mental status
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Ans: A Feedback: The degree of HF is often calculated by the number of pillows required to get relief (e.g., one-pillow, two-pillow, or three-pillow orthopnea). Fluid overload is associated with HF so skin turgor is not an indicator of improvement. Regular heart rate and normal cognition can be found with acute flare-ups of HF so these findings would not indicate improvement.
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The nurse suspects the patient may have toxic levels of digoxin in the bloodstream when what is assessed? (Select all that apply.) A) Irregular heart rhythms B) Nausea C) Anorexia D) Headache E) Peripheral edema
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Ans: A, B, C Feedback: Digoxin toxicity is a serious syndrome that can occur when digoxin levels are too high. The patient may present with anorexia, nausea, vomiting, malaise, depression, irregular heart rhythms including heart block, atrial arrhythmias, and ventricular tachycardia. Peripheral edema is indicative of heart failure, not digoxin toxicity. Headache is not usually associated with digoxin toxicity.
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The patient has been prescribed inamrinone (Inocor). Before administering the drug the nurse needs to know the drug has what pharmacokinetic effect? A) Decrease in cyclic adenosine monophosphate (cAMP) B) Decrease in cardiac output C) Increase in cardiac preload D) Increase in cAMP
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Ans: D Feedback: Inamrinone is a phosphodiesterase inhibitor that blocks the enzyme phosphodiesterase. This blocking effect leads to an increase in myocardial cell cAMP, which increases calcium levels in the cell. These drugs do not decrease cardiac output or increase cardiac preload.
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The patient has just been prescribed milrinone (Primacor). The nurse recognizes the drug is contraindicated due to the patient's allergy to what? A) Penicillins B) Salicylates C) Opioids D) Bisulfites
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Ans: D Feedback: Phosphodiesterase inhibitors are contraindicated in the presence of allergy to the drug or to bisulfites. Penicillins, salicylates, and opioids have no contraindications when used with milrinone.
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The nurse administers a human B-type natriuretic peptide with the expectation it will have what action? A) Decrease blood volume B) Increase force of cardiac contraction C) Reduce venous return D) Lighten the heart's workload
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Ans: C Feedback: Human B-type natriuretic peptides are normally produced by myocardial cells as a compensatory response to increased cardiac workload and increased stimulation by the stress hormones. They bind to endothelial cells, leading to dilation and resulting in decreased venous return, peripheral resistance, and cardiac workload. They also suppress the body's response to the stress hormones, leading to increased fluid loss and further decrease in cardiac workload. Diuretics decrease blood volume, cardiac glycosides increase force of contraction, and vasodilators lighten the heart's workload.
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The nurse expects the patient's heart failure (HF) is caused by what diagnosis that is responsible for 95% of the cases diagnosed? A) Cardiomyopathy B) Hypertension C) Congenital anomaly D) Coronary artery disease (CAD)
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Ans: D Feedback: CAD is the leading cause of HF, accounting for approximately 95% of the cases diagnosed. CAD results in an insufficient supply of blood to meet the oxygen demands of the myocardium. Consequently, the muscles become hypoxic and can no longer function efficiently. When CAD evolves into a myocardial infarction, muscle cells die or are damaged, leading to an inefficient pumping effort. Cardiomyopathy, hypertension, and congenital anomaly are rarely associated with heart failure.
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The nurse prepares to administer a phosphodiesterase inhibitor by what route? A) Oral B) IV C) Subcutaneous D) Intramuscular
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Ans: B Feedback: Phosphodiesterase inhibitors are only given IV. They cannot be given orally, intramuscularly, or subcutaneously.
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The nurse is caring for a patient who has digoxin toxicity. As the nurse assesses the changes in the patient's daily activities, what finding could indicate the cause of the toxic level? A) The patient has been sleeping more lately. B) The patient took nitroglycerin for chest pain twice yesterday. C) The patient's daughter brought her a bag of licorice that she has been enjoying. D) The patient's intake of sodium increased lately because she's been eating seafood.
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Ans: C Feedback: Increased digoxin toxicity has been reported with ginseng, hawthorn, and licorice. Patients should be advised to avoid these combinations. Increased sodium intake will exacerbate the patient's heart failure, which might explain why she is sleeping more and requiring nitroglycerin but these actions did not contribute to the digoxin toxicity.
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The nurse admits a patient to the constant care unit with a digoxin level of 11 ng/mL and a serum potassium level of 5.2 mEq/L. Digoxin immune Fab is administered. The next day, the patient's digoxin level remains elevated. What action does the nurse anticipate? A) Administer digoxin immune Fab again. B) Administer a reduced dosage of digoxin. C) Continue to monitor the patient's digoxin level daily. D) Notify the health care provider of the elevated level.
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Ans: C Feedback: Serum digoxin levels will be very high and unreliable for about 3 days after the digoxin immune Fab infusion because of the high levels of digoxin in the blood. The patient should not be redigitalized for several days to 1 week after digoxin immune Fab has been used, because of the potential of fragments remaining in the blood. There is no need to notify the health care provider or to administer digoxin immune Fab again.
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The nurse is preparing to administer a digitalizing dosage of digoxin to a geriatric patient. What factors will the nurse assess for first to avoid digoxin toxicity? (Select all that apply.) A) Renal function B) Low body mass C) Hydration D) Assessment of pulse E) Cognitive function
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Ans: A, B, C Feedback: Factors that may contribute to elevated digoxin levels include impaired renal function, low body mass, and dehydration. Assessment of pulse and cognitive function are always important when caring for a geriatric patient, but they will not contribute to elevated digoxin levels.
