A nurse in the ER is caring for a patient who had fallen at home. She reviews the blood pressure reading of 160/80 mm Hg. The client denies any history of hypertension. Which of the following actions should the nurse take first?

To administer the ordered dose of digoxin, you need to calculate how many tablets of the available strength are equivalent to 0.25 mg. You can use the formula:

Ordered dose / Available dose = Number of tablets

Plugging in the values, you get:

0.25 mg / 0.125 mg = 2 tablets

Therefore, you need to administer two tablets of digoxin 0.125 mg to give the ordered dose of 0.25 mg.

A. Take the blood pressure:

Assessing blood pressure is a critical initial step when a patient is experiencing dyspnea. It helps provide information about the patient's overall cardiovascular status, which is essential in determining the severity of the dyspnea and guiding subsequent interventions.

B. Remove the pillow from under the patient’s head:

Removing the pillow may be a relevant intervention if the patient is in a position that could be contributing to respiratory distress. However, the priority is to first assess vital signs, particularly blood pressure, to gather information about the patient's cardiovascular status.

C. Elevate the foot of the bed:

Elevating the foot of the bed may be a consideration if the dyspnea is related to conditions such as heart failure, where raising the legs can help reduce venous return and decrease the workload on the heart. However, the initial priority is to assess blood pressure to guide appropriate interventions.

D. Elevate the head of the bed:

Elevating the head of the bed may be beneficial for patients with respiratory distress to improve ventilation and oxygenation. While this intervention may be appropriate, the first action should be to assess vital signs, particularly blood pressure, to gain an overall understanding of the patient's condition.