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
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
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Complete Heart Block: Complete heart block (third-degree AV block) occurs when there is no communication between the atria and ventricles. The atria and ventricles beat independently, resulting in a very slow ventricular rate. This rhythm is characterized by regular P waves that have no relation to the QRS complexes.
B. Sinus Tachycardia: Sinus tachycardia is a rhythm originating from the sinoatrial node with a heart rate typically between 100-150 beats per minute. The rhythm is regular, and the P waves precede each QRS complex consistently.
C. Ventricular Tachycardia: Ventricular tachycardia is a fast heart rhythm that originates from the ventricles. It is characterized by wide and abnormal QRS complexes with a rate usually between 150-250 beats per minute. There may be no visible P waves, and if present, they are not associated with the QRS complexes.
D. Idioventricular Rhythm: Idioventricular rhythm is a slow rhythm originating from the ventricles with a heart rate usually between 20-40 beats per minute. It has wide and abnormal QRS complexes and no visible P waves.
Correct Answer is ["B","D","E"]
Explanation
A. Consumes spicy snacks daily: Consuming spicy snacks daily is not a known risk factor for laryngeal cancer. Risk factors for laryngeal cancer typically include tobacco use, alcohol consumption, exposure to certain chemicals, and occupational hazards.
B. Uses flavored chewing tobacco: Chewing tobacco, especially flavored varieties, is a known risk factor for laryngeal cancer. Tobacco contains carcinogenic substances that can damage the cells of the larynx, increasing the risk of cancer development.
C. Employed as x-ray technician: Being employed as an x-ray technician is not a known risk factor for laryngeal cancer. However, prolonged exposure to radiation may increase the risk of other types of cancer, such as lung cancer.
D. Partner smokes cigarettes: Secondhand smoke exposure from a partner who smokes cigarettes is a risk factor for laryngeal cancer. Inhaling tobacco smoke, even indirectly, can expose the individual to carcinogens that may contribute to the development of cancer.
E. Employed as industrial painter: Occupational exposure to certain chemicals, such as those found in paint and industrial solvents, is a known risk factor for laryngeal cancer. Industrial painters may be exposed to carcinogens through inhalation or skin contact, increasing their risk of developing cancer.
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