Bowtie: Cardiac Glycoside – NCLEX-RN®

by Rhonda Lawes, PhD, RN

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    00:00 Hi, I'm Professor Lawes, and welcome to this portion of our NCLEX review.

    00:05 Now in this one, we're gonna start looking at one of the special types of questions that NCLEX started on April 1st, 2023.

    00:15 Okay, this one is called a bowtie, and I'll explain it to you.

    00:19 First of all, I want you to know that you are perfectly capable of doing this, I promise.

    00:26 I'm going to walk you through step by step, the strategies that you should use.

    00:30 And you'll be able to, with some practice, do these beautifully, okay? I really never thought I'd see the day where we saw a question type that people were more worried about than select all that apply.

    00:41 But these next gen ones have really become that for people.

    00:45 So you're ready.

    00:46 The topic of this one is we're going to look at cardiac glycosides.

    00:50 So that gives you a little hint, because we're just working together and practicing.

    00:55 So let's start with a case scenario.

    00:57 Now, when you're on your NCLEX, it's not going to look this lovely, you're not going to have beautiful graphics and have a story.

    01:04 But we did this because we want you to do that in your own mind.

    01:08 As you're reading about the case studies, or the bowtie or whatever type question we're on, I want you to picture what is going on in your mind.

    01:16 Why? Well, the more you focus your brain by picturing these as real people experiencing things, you're going to make better and safer, and therefore have a better chance of picking the correct answer.

    01:30 Okay, so let's take a look at the picture here.

    01:33 This is an older adult, now they're brought to the emergency department by a family member.

    01:37 So the family member says the client seems confused, and has had some nausea and vomiting all day.

    01:45 First clue, when you're being introduced to the case or to the experience, you want to know if anything is normal or abnormal.

    01:54 So the family member told us what about this particular patient? They said they seem confused.

    02:00 Now, if we had the opportunity to ask, we would ask if this is new behavior, but because it's presented to us like this, we just think, okay, that's not regular, they seem confused.

    02:10 They've had nausea, Whoa, that is definitely abnormal.

    02:14 Nobody likes that and they've been vomiting all day.

    02:19 Okay, so far, all we know, older adult, seems confused, and has abnormal nausea and vomiting, we have no idea what the cause is.

    02:30 So this is a good point to...

    02:34 Just take a deep breath.

    02:35 All those negative thoughts that are going through your mind, send them away.

    02:40 You are sharp enough to get this.

    02:43 The key is just going through slowly and practicing.

    02:46 So we've pictured it we've got this image in our mind, you'll have your own image when you're taking the NCLEX exam.

    02:52 Now let's start to take a look at the tub that has nurses notes.

    02:55 These are the types of things you'll be able to read in the question.

    03:00 Client states: "everything looks yellow", and "my heart feels like it's skipping." Okay, now, you know, that's an assessment, right? The patient is communicating to us.

    03:11 So you always ask yourself, "Is that normal, or abnormal?" Everything looks yellow, that is not normal.

    03:19 My heart rate feels like it's skipping.

    03:22 That is also not a normal feeling.

    03:24 If the patient is in normal sinus rhythm, it should feel very regular.

    03:28 In fact, they shouldn't really be able to feel it at all.

    03:32 Now the client looks visibly drowsy by closing eyes at times during the interview, got a picture.

    03:39 So they can hardly keep their eyes open while they're talking to the nurse.

    03:43 So so far, we know abnormal, everything looks yellow, my heart feels like it's skipping.

    03:48 You may be starting to connect the dots yet, but if you haven't, no worries.

    03:52 We know we have abnormal assessment, and the patient seems really drowsy or sleepy.

    03:57 Now we look at their medical history, they have type 2 diabetes, remember there's a difference type 2 diabetes, and congestive heart failure.

    04:07 So that's what we know about their background and their history.

    04:10 Now the most recent historical information from you're looking at the medical record, states a Dima from the CHF has recently worsened.

    04:19 Okay, that's a change.

    04:20 We're always on the lookout when things are a change, and the physician increased the client's daily dose of furosemide.

    04:28 Now I know when everyone here so trug name, it just makes you nervous makes your heart feel funny and like it's skipping, don't worry.

    04:35 We're going to do our very best to prepare you for the most likely drugs that are on the NCLEX.

    04:40 But at the end of the day, nobody knows exactly what's going to be on the NCLEX.

    04:46 But we can help you review with the most likely drugs.

    04:49 But if you come up on a drug on a test question and you have no idea what it is, it's okay.

    04:56 Tell yourself that could happen.

    04:59 We'll just teach you how to look for cues within the question.

    05:01 So now remember, we're going through this much more slowly than you will when you're taking a question because I want you to learn skills, like here.

    05:11 As we're going through the nurses notes, I want you to notice anything that's abnormal, looks yellow, heart feels like it's skipping, patient is drowsy.

    05:20 We know that their CHF has recently worsened.

    05:25 And they've increased the dose of furosemide.

    05:27 So we know they're on that which is a loop diuretic, and they have a history of type 2 diabetes and CHF.

    05:34 So I have this solid before I continue reading.

    05:40 So we've got the medication that the patient is on, whoa, right there.

    05:45 Furosemide 80 mg PO daily, that's a pretty stout dose.

    05:49 Now, PO means oral.

    05:51 So they're taking that and hopefully they are taking it in the morning.

    05:55 Because, you know, once a patient takes this medication, it's gonna encourage them to urinate or to lose extra fluid.

    06:01 And so they're gonna be going to the bathroom a lot.

    06:03 So, Furosemide 80 mg PO daily, and we learned in the notes that the doctor just recently increased that.

    06:10 They're on Digoxin 0.25 mg by mouth daily, we know that's a cardiac glycoside.

    06:18 And they're on Glyburide 5 mg by mouth daily.

    06:22 Now, that's a treatment for blood sugar, right? That helps lower patient's blood sugar.

    06:28 So we're on Furosemide which is a diuretic, or on Digoxin is a cardiac glycoside which strengthens the force of the heartbeat and decreases the heart rate.

    06:38 And Glyburide, which will help take care of the patient's blood sugar by lowering it because they're a type 2 diabetic.

    06:46 Now, every patient on admin is going to have vital signs taken, and you'll see these listed out within the question.

    06:52 So let's just start from the top work our way down.

    06:55 Here's the question I want you to ask yourself every time, is this normal or abnormal? I know, you're gonna hear me say that over and over again.

    07:04 But I promise you, that's the key to getting these questions correct.

    07:09 Okay, so we've got an axillary tem.

    07:10 Don't ask me why they took an axillary tem, that's really not what we normally do.

    07:14 But let's just work with it.

    07:16 That's an example of you're going to see things on NCLEX questions and go, "Well, that doesn't make sense." Don't waste the energy, right? You can argue with the screen, it means nothing to your success.

    07:27 Just take it at that face value.

    07:30 That's the type of temperature they took, let's see if it's normal.

    07:33 Is that within normal limits? Yeah, it's fine.

    07:37 What about the blood pressure? Is that normal? No, that is not fine.

    07:44 In NCLEX world, a normal blood pressure is 120/80.

    07:49 I know that's not realistic for real world, but use that as a gauge that normally 120/80 is considered normal.

    07:57 This blood pressure is significantly lower, 84 systolic over 60 diastolic.

    08:03 This is low and abnormal.

    08:05 Pulse 48 beats/minute, and irregular.

    08:10 Strike 2, right? 48 beats a minute is too slow.

    08:14 Because in NCLEX world, we know normal is 60-100, the same numbers for sinus rhythm.

    08:20 Irregular, always mean something weird is going on.

    08:24 Now, it might not be life threatening, but it's not normal.

    08:28 Respiratory rate, oh, wow, 12 breaths a minute, that's a little kind of slow for an adult, right.

    08:35 And oxygen saturation is 92% on room air.

    08:40 Now, I would expect that to be a little higher.

    08:43 So things don't look particularly well.

    08:46 They're not in maybe an imminent code.

    08:48 But that's a really low blood pressure.

    08:51 That's a low heart rate, and it's irregular.

    08:55 So we're going to really keep a close eye on this person.

    08:58 Now I know some of you're saying, "Hey, what about that respiratory stuff, I always hear that we should deal with respiratory first.

    09:03 Respiratory is always a priority.

    09:06 But this patient is at 92%.

    09:08 They're okay, then I'm going to keep an eye on it.

    09:12 This likely means at this point, my highest priority is going to be that blood pressure, pulse and irregular rhythm.

    09:19 Okay, now, let's take for a minute.

    09:21 I know that this part is really frustrating as students because you feel like, "Oh, there's multiple right answers" and you are correct.

    09:30 What this test is looking for is are you safe in practice? Do you recognize what's the highest priority or the biggest emergency that you should follow up on? So try and shake off that frustration.

    09:43 We all have it.

    09:44 But just think like you were caring for someone that was really important to you.

    09:49 You'd want to address the biggest problem first, the biggest risk first.

    09:54 So if you're in that type of mindset, hopefully it will be less frustrating for you because our goal is that you take the NCLEX one time and you pass it and get onto your practice.

    10:07 Now they draw some labs, the results are pending.

    10:10 You'll see this in the question as you go through.

    10:14 Now look at what you see on the screen here.

    10:16 This is what a question will look like.

    10:18 I'm gonna blow it up and break it down much easier for you.

    10:21 But I want you to get a feel for what you'll experience on the test.

    10:24 See that tab there that says nurses notes, you'll be able to click on the next one that says medications and the next one that says vital signs.

    10:33 All those things we just talked about.

    10:36 So when you're sitting down, and you're taking an actual bowtie question, this is what it's going to look like.

    10:43 You'll have the ability to click in between tabs as many times as you want.

    10:48 What I recommend is, though, you go slowly through it one time, then go through the next tab, go through the next tab, then go back and summarize.

    10:58 What do I see is the biggest problem here.

    11:00 Same thing with medications and vital signs.

    11:03 Before I start looking at, what should I do? What's the condition? What should I monitor? The more time you spend on these tabs, just like I recommend that you do on the stem of the question.

    11:15 The more time you spend here, the better chance you're going to have of making sure you are clearly focused and you're going to get the correct answers next.

    11:25 Okay now see why we call it a bowtie? I have two on the side, one in the middle and two on the side, it looks kind of like a bowtie.

    11:33 So that's why you'll hear them call that it doesn't matter if you know, that's the name of the question.

    11:38 That's just the type of question it is.

    11:40 It has no bearing on your score or how you walk through it.

    11:44 I just want to show you always start left to right.

    11:48 Work yourself through in a systematic manner, slow and steady wins the race and passes the test.

    11:56 So we see this question.

    11:57 We've worked through our tabs, nurses notes, can you remember what's weird about that? Everything seems yellow.

    12:04 We've got this he feels really drowsy.

    12:06 He's got CHF type 2 diabetes, we know that his edema has increased.

    12:11 So we started on furosemide, increased furosemide.

    12:15 Medications, he's got a diuretic, he's got a cardiac glycoside.

    12:19 And he's got something for his blood sugar, which is in the sulfonylurea group.

    12:24 Vital signs.

    12:26 None of them were perfect, but the ones that were most concerning was slow and irregular heart rate.

    12:32 And he had a really low blood pressure.

    12:37 One more thing I want to point out about the format of this question, when you're taking an actual NCLEX exam, you see the bowtie on top.

    12:44 And we've already talked about why it's that shape.

    12:47 But look at these three columns on the bottom.

    12:50 Now, if you just allow your mind to row through there, you are going to get overwhelmed.

    12:53 Remember, left to right, until you're really well practiced on these.

    12:58 But I would recommend you use that strategy even on the exam.

    13:02 Because when you're taking the NCLEX, you are stressed and stressed brains that can respond to routines do much better.

    13:10 So let's look at those three columns.

    13:12 You see that the one on the left is what you got actions to take.

    13:16 Now, we have 1, 2, 3, 4, 5 options there.

    13:22 So while you have five options, only two of those will be correct.

    13:27 So we'll work together and make sure that we help you learn the strategies for eliminating three of those.

    13:34 So we land on the two highest priority.

    13:37 Now move to the middle column that says potential condition.

    13:41 How many options do you have there? Well, you got four, right? But only one of those will be correct.

    13:48 Now move over to the third column.

    13:50 Those are the things that we're going to monitor.

    13:53 How many answer choices do you have? Five again.

    13:57 But how many are going to be correct? Two.

    14:01 Okay, so why are we taking so much time walking through this? Because we know that this is different than the types of exams you've likely taken in nursing school.

    14:09 And we want you to be very familiar with what the format is like.

    14:14 So while we have all this to look at, right now, I want you to laser focus on that column that's on the left, the actions to take.

    14:23 Ready? Well, let's keep walking through this.

    14:29 Actions to take, first one I'm going to take a look at is administer insulin.

    14:33 Now think back about what you know about our patient.

    14:35 Does it make sense that they get insulin? Well, they are a type 2 diabetic, but we didn't get any blood sugar information.

    14:45 So does that seem to be the most important? Well, I don't think so.

    14:50 But you could leave it in for now if you wanted to.

    14:52 Don't move it up yet but just kind of leave it in.

    14:54 Notice these patients on oral anti-diabetic medications already.

    14:59 And I'm guessing that blood sugar is not the most urgent need.

    15:03 But if you're not sure yet, you can go ahead and just leave it in.

    15:07 If you are sure, here's where you could eliminate it.

    15:10 Now next is talking about giving a potassium sparing diuretic.

    15:15 Well, I know that this patient has had increasing edema because of their CHF, their physician has increased their furosemide to 80 mg a day.

    15:24 Would it make any sense to increase and add another diuretic? No. And plus a potassium sparing diuretic is a really weak diuretic so it's not going to do more.

    15:37 It's not going to add anything to the diuresis that 80 mg of furosemide isn't taking care of.

    15:43 So I can absolutely get rid of that one.

    15:47 Now, what's next, we're moving left to right.

    15:50 Draw a blood culture.

    15:52 Is there any reason? What would a blood culture tell me about? Well, based on what I know about this patient, I don't see any signs of infection because I don't get anything and report that it was temperature was normal.

    16:06 So I'm going to eliminate that one.

    16:09 So, so far, I have officially eliminated giving a potassium sparing diuretic, and drawing a blood culture.

    16:16 Now I'm gonna go back to the next one, perform a 12-lead ECG.

    16:22 Okay, where their heart rate is really low.

    16:24 And they are irregular.

    16:27 And I think about the medications are having pretty high doses of furosemide and they're on digoxin.

    16:33 Yeah, that makes sense.

    16:34 Let's find out what's going on with his heart rate.

    16:38 So I'm going to leave that one in, I'm going to go ahead and move that up.

    16:41 I feel pretty confident.

    16:44 Now the final one moving left to right is blood pressure is low.

    16:49 But the heart rate is low.

    16:51 Because you're saying administer TKO IV fluids.

    16:54 I'm looking at that thinking TKO is oh, to keep open, that means they've got an IV started in the arm.

    17:03 And they're just dripping a tiny amount of fluids in there to keep that IV line open in case they have to give any IV medications.

    17:10 So the answer choice is administer TKO IV fluids.

    17:15 And I'm thinking, why would that help the patient? Well, their blood pressure is low, but their heart rate is low.

    17:21 So I don't really think they're hypovolemic.

    17:24 And I don't think that's an issue because with hypovolemia, low volume, their blood pressure will be low, but their heart rate will be high because their heart compensates.

    17:33 48 is not high.

    17:36 So administering TKO IV fluids is not really going to address their blood pressure.

    17:42 So I don't think it's hypovolemia.

    17:45 But we are going to need IV access.

    17:47 But let's go back to that other one I left in.

    17:50 What was our other option? Do you remember? The first one on the left.

    17:56 Administer insulin.

    17:58 Okay, so yes, this is the classic story we always say, I get it down to the last two, and then I pick the wrong one.

    18:07 Well, here's what I want you to think about based on what I know on this patient.

    18:10 Which one of these strategies would keep them the safest? Would it be safer to have IV access and a keep open rate? So I could put medications in there if I needed them quickly or to give the patient insulin that we have no idea they're on it or if their blood sugar is even high.

    18:28 Okay, well, when we say it that way, it seems to make a lot more sense, doesn't it? That's exactly what I want you to do.

    18:36 Here's why I don't want you looking at that middle column, I want you to pick the actions to take before you even look at the options for what might be going on with that patient.

    18:47 So perform 12-lead, administer TKO IV fluids.

    18:51 Those are the ones we're going to slide into the action to take.

    18:55 Now we move into that middle column.

    18:58 And what is in that middle column? The potential condition.

    19:02 Yes, this is the one I don't want you focusing on? Because otherwise, you see what we have there.

    19:08 We've got dehydration, sepsis, digoxin toxicity, hyperosmolar hyperglycemic syndrome, which is HHS.

    19:14 And what do any of those have to do with all those items? Well if you start looking at potential conditions and trying to match them up for the actions to take, you're going to get confused.

    19:24 But because you avoided this column until you looked at the left, and you logically and rationally sorted through each of those in eliminate the answers.

    19:33 Now let's go through and see what makes the most sense.

    19:37 Where are we starting? Left to right.

    19:40 So do you think it is dehydration? Well, the blood pressure is low.

    19:45 But we already talked about if the blood pressure is low, the heart rate would be high if it's hypovolemia.

    19:51 And we know that this patient's heart rate is also low.

    19:54 So therefore blood pressure is low because their heart is not beating fast, right.

    19:59 And heart rate has a huge impact on what a patient's blood pressure is.

    20:04 So this is not likely dehydration, although you might be thinking but they're on furosemide.

    20:10 I know that but we would see different signs in their vital signs.

    20:15 If the lasix had knock them down so low that it made them intravascularly dehydrated, so we can get rid of that one.

    20:23 Next one, sepsis.

    20:26 See, they through those other actions to take in there to see if you would jump too quickly, because you don't see any signs of sepsis.

    20:34 That's why we skipped some of those other options that we would do, because we're looking for the focus of the question.

    20:43 We're looking for the focus, which is right now, low heart rate, irregular, low blood pressure, those are the biggest danger signs.

    20:50 And we don't see any sign of sepsis, and their temperature was within normal limits.

    20:56 So we know that it is not sepsis, we can eliminate that.

    21:00 Okay, Digoxin toxicity.

    21:02 First of all, is the patient taking dig? Yes, they are taking dig.

    21:07 Okay, so looking at their vital signs, what are the signs of dig toxicity? Is a low heart rate, a sign of dig toxicity? What about irregularity? Yes, those are both signs of digoxin toxicity.

    21:23 So right now I'm definitely keeping that one in, ruled out dehydration, ruled out sepsis with a little information that we had, dig toxicity makes much more sense with the information that we have or the topic of the question.

    21:36 Now, let's go to hyperosmolar...

    21:39 Alright, we got the HHS.

    21:41 Okay, this is something that happens in type 2 diabetics.

    21:44 The patient is type two diabetic, takes a long period of time for it to develop.

    21:49 But what happens is the patient pees out so much fluid and volume, they are intravascularly dehydrated.

    21:57 They have these really high blood sugars, and they're getting rid of all of this volume.

    22:01 So they come in extremely intravascularly dehydrated.

    22:06 So their heart rate would be up, and because of all the polyuria, and their blood pressure would be down, this patient is not showing those signs.

    22:14 And that's why we can rule out HHS, I'm very comfortable.

    22:18 So looking back at our options, which one makes the most sense as our potential condition? Now the cool thing about NCLEX is you only have to deal with one potential condition at a time, right? Patients don't come into us in ER, and I just recently spent 24 hours in an ER with a family member.

    22:37 They come in with all kinds of multiple diagnoses, but in NCLEX world, just one at a time.

    22:44 So in this one, our best option is dig toxicity.

    22:47 Now, as you pick this potential condition, ask yourself, "Does this make sense?" Why do I think this makes sense? Well, the heart rates affected the blood pressure is affected.

    22:56 And I know the patient is on this medication.

    22:59 They also described something when they first came in that is an unusual sign budding known sign of dig toxicity.

    23:06 Do you remember what that was? Everything looks yellow.

    23:11 All right, that's another sign for dig toxicity.

    23:15 Think back about what they said about their GI symptoms.

    23:18 Ooh, nausea and vomiting.

    23:21 Those also line up with dig toxicity.

    23:23 So all those things were pointing towards dig toxicity.

    23:27 Now, we didn't talk a lot about the initial stuff when we first walked through these.

    23:31 That's why I want to make sure you always go back at the end and say, "Does this potential condition makes sense?" Yes, we think it does.

    23:40 Now go back and look, does it make sense to do an EKG? Yes.

    23:44 Does it make sense to administer TKO IV fluid so we have IV access? Yes.

    23:50 All right. So we know we're doing well.

    23:52 Now we're going to finish the third and final portion of this bowtie question.

    23:57 We're going to look at the parameters to monitor.

    24:00 Okay, this is saying, do you know how to keep this patient safe? You recognize when they're in danger, but do you know how to keep them safe? What do you need to keep an eye on? So which way are we going to start? Left to right.

    24:13 You're correct.

    24:15 So working from the left, we've got, "Are you going to monitor their potassium level?" Well, they are on furosemide, which is a loop diuretic and we know that that can cause a low potassium.

    24:27 Would that make sense to monitor that? Seems like a good idea.

    24:30 Oh, and potassium.

    24:32 Potassium is really important to the heart.

    24:36 So I'm going to leave that one in for now but I'm going to keep working through.

    24:42 The angry yells at right these questions are trying to catch us.

    24:45 So if you said sepsis, white blood cell count would make sense.

    24:49 But we already know dig toxicity is what we feel is the best answer.

    24:54 So there's no reason to get a white blood cell count, we likely will get a whole panel of things, but it's not what's going to keep the patient safest.

    25:02 Is a potassium level more important than a white blood cell count? Yes, particularly because we don't see any signs of infection.

    25:10 Those of you that work in an area, I know, you're saying, "Ah ah, we would get all that." I know you would, but that's real life practice.

    25:16 In NCLEX world, we're focusing on just this intervention.

    25:21 So it does not make sense for white blood cell count to be drawn on top over potassium level, the potassium level is more important to keep them safe.

    25:32 Now, hourly blood glucose level that would tell us why we've got some real problem going on here.

    25:38 This one's kind of tricky, because you're like, well, they are diabetic, they are kind of unstable, but the initial glucose will be drawn.

    25:45 And we don't know what that was.

    25:46 But there's no need to check this every hour at this point.

    25:50 It's not more important than a potassium level.

    25:54 Now, what about continuous cardiac monitoring? Oh, yeah, that's way more important than a blood glucose and a CVC or white blood cell count, because dig toxicity impacts the heart.

    26:06 And we know that you could see a slow and irregular heartbeat, which we are so in case it gets slower and more irregular, we want to make sure that they're on continuous cardiac monitoring, so I can be eyeing up all the time.

    26:20 So right now, I'm pretty convinced that as potassium and cardiac monitoring, do I even need to look at the last answer.

    26:26 Yes. Yes, you do.

    26:29 Always eliminate the wrong answers to make sure that you have the most correct answers.

    26:35 The ones for this particular patient in this particular setting, do they keep them the safest? Okay, now continuous electroencephalography.

    26:44 Okay, that's a big old word.

    26:46 And I just learned that one, but it's easier to say EEG.

    26:50 Now, this monitors your brainwaves.

    26:53 That's not necessary to monitor that in dig toxicity.

    26:56 So can I eliminate that one? Yeah, I feel pretty comfortable.

    27:00 I've got the rationale of why I would monitor potassium.

    27:04 I've got the rationale of why I would put them on continuous cardiac monitoring.

    27:09 So the two answers here, you drag and drop them and move them right over to the right side of our bowtie.

    27:17 And that's it.

    27:18 You have done it.

    27:19 You have walked through a bowtie question and you did it exquisitely.

    27:24 So thanks for watching this video for us.

    27:26 Join us in our other videos and we'll continue to break down NCLEX questions for you and good luck when you take your exam.

    About the Lecture

    The lecture Bowtie: Cardiac Glycoside – NCLEX-RN® by Rhonda Lawes, PhD, RN is from the course Next Gen NCLEX-RN® Question Walkthrough.

    Included Quiz Questions

    1. Irregular heart rate
    2. Bradycardia
    3. Nausea
    4. Visual disturbances
    5. Hypertension
    1. Administer oxygen via nasal cannula
    2. Administer the client’s daily medications
    3. Call the healthcare provider
    4. Initiate intravenous access
    1. Withhold the client’s morning dose of digoxin
    2. Call the client’s healthcare provider
    3. Administer oxygen via nasal prongs
    4. Perform a 12-lead ECG
    1. Actions to take
    2. Potential condition
    3. Parameters to monitor
    4. Assessment findings
    1. Actions to take
    2. Potential condition
    3. Parameters to monitor
    4. Assessment findings
    5. Likely outcomes

    Author of lecture Bowtie: Cardiac Glycoside – NCLEX-RN®

     Rhonda Lawes, PhD, RN

    Rhonda Lawes, PhD, RN

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