A nurse is caring for a client diagnosed with congestive heart failure and is taking digoxin daily. The client refused breakfast and is complaining of nausea and weakness. Which of the following actions should the nurse take first?

Check an apical pulse

Request a dietitian consult.

Request an order for an antiemetic

Suggest that the client rests before eating the meal

Answer and Explanation

The Correct Answer is A

A. Check an apical pulse: Digoxin is known to cause toxicity, which can manifest as nausea, weakness, and anorexia. Bradycardia is a common sign of digoxin toxicity. Therefore, the nurse's first action should be to assess the client's apical pulse rate to determine if there are any signs of bradycardia, which could indicate digoxin toxicity.

B. Request a dietitian consult: While nutrition is important, the client's symptoms of nausea and weakness need immediate attention to rule out digoxin toxicity before considering dietary interventions.

C. Request an order for an antiemetic: Administering an antiemetic may be indicated if the client is experiencing nausea, but it's crucial to assess for digoxin toxicity first, as antiemetics may mask symptoms of toxicity.

D. Suggest that the client rests before eating the meal: Rest may be beneficial for the client, but addressing the potential cause of the symptoms, such as digoxin toxicity, takes priority

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Correct Answer is B

Explanation

A. This result shows a slightly elevated PaCO2, which could suggest respiratory compensation for a metabolic alkalosis, not acidosis, as the pH is within the normal range.
B. This result indicates both a low pH and an elevated PaCO2, which are consistent with respiratory acidosis. The low HCO3 also suggests a metabolic acidosis component, making it the best match for a client with acidosis.

C. The elevated pH indicates alkalosis. The low PaCO2 and high HCO3 further suggest a primary respiratory alkalosis with metabolic compensation.
D. These values are within normal limits, indicating neither acidosis nor alkalosis.

A. Client calm not agitated. Grimaces with movement. B. Oral mucous membranes dry. C. Axillary temp 102 F (38.9 C), client shivering. D. Productive cough. E. Coarse rhonchi bilaterally. Crackles in bases. F. Respirations irregular with periods of apnea G. Client resting in recliner. RR 12, regular

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"B"},"C":{"answers":"C"},"D":{"answers":"B"},"E":{"answers":"C"},"F":{"answers":"A"},"G":{"answers":"A"}}

Explanation

Client calm not agitated. Grimaces with movement.
No change: While the client is calm and not agitated, grimacing with movement indicates continued discomfort or pain, which remains unchanged.
Oral mucous membranes dry.

No change: Dry oral mucous membranes persist, suggesting ongoing dehydration or inadequate oral hydration.
Axillary temp 102 F (38.9 C), client shivering.

Declined: The axillary temperature has increased from 100.8 F (38.22 C) to 102 F (38.9 C), indicating a worsening of the client's fever. Shivering suggests the body's attempt to generate heat in response to the fever.
Productive cough.

No change: The client continues to have a productive cough, indicating ongoing respiratory congestion or infection.
Coarse rhonchi bilaterally. Crackles in bases.

Declined: The presence of coarse rhonchi bilaterally and crackles in the bases suggests worsening respiratory status, possibly indicating progression of underlying lung disease or development of complications such as pneumonia.
Respirations irregular with periods of apnea.

Improved: The client's respirations, previously irregular with periods of apnea, are now regular, indicating an improvement in respiratory function.
Client resting in recliner. RR 12, regular.

Improved: The client's respiratory rate has decreased from 18 to 12 breaths per minute, and respirations are now regular, suggesting improved respiratory status and possibly reduced distress.

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A nurse is caring for a client diagnosed with congestive heart failure and is taking digoxin daily. The client refused breakfast and is complaining of nausea and weakness. Which of the following actions should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reviewing a client's arterial blood gas (ABG) results. Which of the following ABG results should the nurse anticipate when caring for a client with acidosis?

Correct Answer is B

Explanation

A nurse caring for a client who is at home on hospice care. Exhibits At the end of the visit, the nurse reevaluates the client. Indicate if the assessment findings are improved, show no change, or show that the client has declined.

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"B"},"C":{"answers":"C"},"D":{"answers":"B"},"E":{"answers":"C"},"F":{"answers":"A"},"G":{"answers":"A"}}

Explanation

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