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 D

Explanation

A. Standing with feet close together when lifting an object does not provide adequate support or balance, increasing the risk of injury. Proper body mechanics involve keeping feet apart for a stable base of support.
B. Putting weight on the heels when moving an object is not advised. Instead, one should keep the weight distributed over the whole foot for stability.
C. When pushing an object, stepping forward with the front foot (rather than moving it backward) helps to maintain balance and applies proper force.
D. Facing the direction of movement is a correct application of proper body mechanics, as it prevents twisting of the spine, reduces strain on the back, and promotes safe movement.

A. Blood pressure of 80/40 mm/Hg B. Oxygen saturation of 95% C. Serum sodium level of 140 mEq/L D. Serum potassium level of 4.8 mEq/L

Correct Answer is A

Explanation

A. A blood pressure of 80/40 mm/Hg indicates hypotension, which is a contraindication for administering furosemide. The medication can further lower blood pressure and increase the risk of adverse effects.
B. An oxygen saturation of 95% is within normal limits and does not indicate a need to withhold furosemide.
C. A serum sodium level of 140 mEq/L is normal and would not warrant withholding the medication.
D. A serum potassium level of 4.8 mEq/L is also normal and safe for furosemide administration, as the medication may cause potassium loss but does not require withholding if the level is within range.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is collecting data from a client at a follow-up clinic visit for acute low back pain. A goal for this client is to use proper body mechanics at all times. Which of the following findings indicates that the client is meeting this goal?

Correct Answer is D

Explanation

A nurse is collecting data from a client who has heart failure prior to the administration of furosemide. For which of the following findings should the nurse withhold the medication?

Correct Answer is A

Explanation

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