A nurse is caring for a 6 year old client who has congestive heart failure and is taking digoxin daily. The client refused breakfast and is complaining of nausea a a and weakness. W Which of the following actions should the nurse take first?
Request a dietitian consult.
Check the client's vital signs.
Request an order for an antiemetic
Suggest that the client rests before eating the meal.
The Correct Answer is B
Rationale:
A. Request a dietitian consult is incorrect because dietary modifications may be important for a child with congestive heart failure, but this is not the immediate priority when the client is showing potential signs of digoxin toxicity.
B. Check the client's vital signs is correct because nausea, vomiting, and weakness in a child taking digoxin can indicate digoxin toxicity, which can affect heart rate and rhythm. The nurse should first assess vital signs, particularly the heart rate, as digoxin toxicity can cause bradycardia or other dysrhythmias, which may be life-threatening. Assessment is always the first step according to the nursing process and the principle of safety first.
C. Request an order for an antiemetic is incorrect because treating symptoms without assessing the client could mask a potentially serious medication-related complication. Administering an antiemetic would not address the underlying risk of toxicity.
D. Suggest that the client rests before eating the meal is incorrect because resting does not address the potential danger of digoxin toxicity. Weakness and nausea may indicate cardiac compromise, so immediate assessment is necessary before implementing comfort measures.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Rationale:
A. Ventricular depolarization is incorrect because this is represented by the QRS complex on the ECG, not the P wave. Ventricular depolarization reflects the electrical impulse spreading through the ventricles, triggering ventricular contraction.
B. Early ventricular repolarization is incorrect because this is represented by the ST segment, which occurs after ventricular depolarization (QRS complex) and before the T wave. Repolarization is part of the recovery phase, not the P wave.
C. Slow repolarization of ventricular Purkinje fibers is incorrect because repolarization occurs primarily during the T wave, not during the P wave. The Purkinje fibers help conduct the impulse rapidly through the ventricles but do not define the P wave.
D. Atrial depolarization is correct because the P wave represents the electrical activity that triggers atrial contraction. It is the first positive deflection on a standard ECG, indicating that the SA node has fired and the atria are depolarizing, which precedes ventricular contraction.
Correct Answer is A
Explanation
Rationale:
A. Administering nebulized albuterol is correct because it is a short-acting beta-agonist (SABA) that provides rapid bronchodilation. During an acute asthma exacerbation, airway constriction is the immediate threat to oxygenation. According to Airway-Breathing-Circulation (ABC) priorities, relieving bronchospasm to restore airflow takes precedence over other supportive measures. Prompt administration of albuterol can quickly improve ventilation, reduce wheezing, and stabilize the patient.
B. Providing immediate rest for the client is incorrect because while reducing physical activity can help conserve energy, it does not directly relieve bronchospasm or improve airflow. Rest alone is not sufficient during an acute exacerbation.
C. Positioning the client in high-Fowler's is incorrect as a sole intervention because it can assist with breathing by maximizing lung expansion, but it does not treat the underlying airway constriction, which is the priority during an acute exacerbation.
D. Initiating oxygen therapy is incorrect as the highest priority in this scenario. Oxygen helps maintain oxygen saturation, but if the airway remains constricted due to bronchospasm, oxygen delivery alone will not correct hypoxemia effectively. Bronchodilation with albuterol addresses the root cause of airflow obstruction.
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