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.
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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Naxlex Comprehensive Predictor Exams
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Correct Answer is B
Explanation
A. Primary dementia is not characterized by temporary or reversible loss of brain function; it typically involves progressive and irreversible changes.
B. Forgetfulness that gradually progresses to disorientation is a common manifestation of primary dementia, indicating cognitive decline.
C. Hyper vigilant behaviors are not typical of dementia; instead, individuals may exhibit confusion or disorientation.
D. Sleeping more during the day than nighttime is not a specific manifestation of primary dementia and could be attributed to other factors, including other medical conditions or medications.
Correct Answer is A
Explanation
A. Managing cholesterol levels is crucial as high cholesterol can lead to plaque buildup in the arteries, increasing the risk of stroke.
B. Using oral contraceptives can actually increase the risk of stroke, especially in women who smoke or have other risk factors.
C. Maintaining a normal blood pressure is essential; elevated blood pressure can lead to increased risk of stroke, not good blood flow.
D. While moderate alcohol consumption may have some benefits, the general recommendation is to limit intake to reduce stroke risk; therefore, stating that up to 3 drinks a day is safe is misleading.
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