A nurse is assisting in the plan of care for a client who is receiving digoxin to treat heart failure. Which of the following actions should the nurse plan to take?

Measure the client's apical pulse rate for 30 seconds before administration.

Withhold the medication if the client's heart rate is above 100/min.

Instruct the client to eat foods that are low in potassium.

Monitor the client for nausea, vomiting, and yellow vision.

Answer and Explanation

The Correct Answer is D

A. The nurse should measure the apical pulse for a full minute (not 30 seconds) before administering digoxin. If the pulse is below 60 beats per minute, the medication should be withheld, making this option incomplete.
B. Digoxin should be withheld if the heart rate is below 60/min, not above 100/min. This statement does not reflect proper nursing protocol.
C. Clients taking digoxin should maintain adequate potassium levels, so advising low potassium intake is incorrect. Foods rich in potassium are encouraged.
D. Monitoring for symptoms such as nausea, vomiting, and yellow vision is essential, as these may indicate digoxin toxicity, making this option correct.

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Correct Answer is C

Explanation

A. A QRS interval of 0.08 second is within the normal range and does not indicate a myocardial infarction.
B. A PR interval of 0.15 second is normal and not indicative of an acute myocardial infarction.
C. ST-segment elevation above the isoelectric line is a key indicator of an acute myocardial infarction (STEMI), signifying myocardial injury.
D. The QT interval being equal to the R to R interval is not a specific indicator of myocardial infarction.

A. Provide a nonskid mat to reduce plate movement. B. Encourage the use of wide grip utensils. C. Remind that the client look for food on the left side of the tray. D. Encourage the client to use her right hand when feeding herself.

Correct Answer is C

Explanation

A. A nonskid mat might be helpful for plate stability, but it does not address the visual deficit related to homonymous hemianopsia.
B. Wide grip utensils are useful for motor difficulties, but the primary issue here is a visual field deficit, not motor impairment.
C. Homonymous hemianopsia results in loss of vision in the same half of the visual field in both eyes. Encouraging the client to turn her head or look for food on the affected side (left side of the tray) can help compensate for the visual loss.
D. While using the right hand may be important after a right-sided stroke, the more pressing issue here is addressing the visual field deficit, not hand preference.

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A nurse is assisting in the plan of care for a client who is receiving digoxin to treat heart failure. Which of the following actions should the nurse plan to take?

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