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
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","D"]
Explanation
A. Recovery phase: The recovery phase occurs after the oliguric phase and is characterized by the gradual improvement of renal function. During this phase, diuresis may occur as the kidneys begin to excrete waste and excess fluid more effectively.
B. Diuretic phase: The diuretic phase follows the oliguric phase and is characterized by increased urine output as the kidneys start to recover and regain their ability to concentrate urine. This phase can lead to electrolyte imbalances and dehydration if not managed properly.
C. Initiation phase: The initiation phase marks the onset of acute renal failure and is characterized by the initial insult or injury to the kidneys. This phase may be triggered by various factors such as hypotension, nephrotoxic medications, or sepsis.
D. Oliguric phase: The oliguric phase is the initial phase of acute renal failure and is characterized by decreased urine output (<400 mL/day). During this phase, waste products and electrolytes may accumulate in the body, leading to metabolic acidosis and fluid overload.
Correct Answer is C
Explanation
A. A diet high in potassium: A high-potassium diet can actually help lower blood pressure and is often recommended for hypertensive patients.
B. Taking benazepril: Benazepril is an ACE inhibitor used to treat hypertension, so it is not a risk factor for developing high blood pressure.
C. Obstructive sleep apnea (OSA): OSA is a significant risk factor for the development of hypertension. The repeated episodes of apnea during sleep can lead to increased sympathetic nervous system activity and elevated blood pressure.
D. High-density lipoprotein (HDL) level of 70 mg/dL: A high HDL level is generally considered protective against cardiovascular diseases, including hypertension.
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