A nurse is caring for a client who has 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?
Request a dietitian consult.
Suggest that the client rests before eating the meal.
Request an order for an antiemetic.
Check the client's vital signs.
The Correct Answer is D
The nurse should check the client's vital signs first because nausea and weakness are signs of digoxin toxicity, which can also cause bradycardia, hypotension, and arrhythmias. The nurse should also assess the client's serum digoxin level, potassium level, and electrocardiogram.
Request a dietitian consult is wrong because it is not the priority action and it does not address the possible cause of the client's symptoms. A dietitian consult may be helpful to provide nutritional education and guidance, but only after ruling out or treating digoxin toxicity.
Suggest that the client rests before eating the meal is wrong because it is not the priority action and it may delay the diagnosis and treatment of digoxin toxicity. The nurse should not assume that the client's symptoms are due to fatigue or lack of appetite, but rather investigate for any underlying problems.
Request an order for an antiemetic is wrong because it is not the priority action and it may mask the symptoms of digoxin toxicity. The nurse should not administer any medications that could interact with digoxin or worsen its effects, but rather notify the provider and follow the protocol for digoxin toxicity management.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Aphasia is a language disorder that affects the ability to understand or produce speech. It can be caused by damage to the brain regions that control language, such as from a stroke. Depending on the type and severity of aphasia, the client may have difficulty with comprehension, expression, reading, or writing. Communication strategies for clients with aphasia include using nonverbal cues, such as gestures, facial expressions, pictures, or objects, to supplement verbal messages and enhance understanding.
The other options are not correct because:
a. "Use simple, childlike statements when speaking." This statement is incorrect because it is patronizing and disrespectful to the client. The client's cognitive and intellectual abilities are not affected by aphasia, only their language skills. The nurse should use simple and clear sentences, but not childish or demeaning ones.
c. "Use a higher-pitched tone of voice when speaking." This statement is incorrect because it is unnecessary and may be irritating to the client. The client's hearing is not affected by aphasia, only their language processing. The nurse should use a normal tone of voice and speak slowly and clearly.
d. "Ask multiple choice questions as part of the conversation." This statement is incorrect because it may be confusing and frustrating to the client. The client may have difficulty with verbal output or comprehension, and
multiple choice questions may add to their cognitive load. The nurse should ask yes or no questions or use gestures or pictures to elicit responses from the client.
Correct Answer is D
Explanation
Moving objects away from the client is an important action to take during a seizure, as it can prevent injury and protect the client from harm.
"Place the client on his back." is not correct, as it can cause airway obstruction and aspiration. The client should be placed on his side, preferably in a lateral recumbent position, to allow saliva and secretions to drain from the mouth.
"Restrain the client." is not appropriate, as it can cause injury, increase agitation, or prolong the seizure. The client should be allowed to move freely during a seizure, but supported and guided away from hazards.
"Insert a padded tongue blade into the client's mouth." is not advisable, as it can cause oral trauma, choking, or damage to the teeth. The client should not have anything inserted into his mouth during a seizure, as he cannot swallow or bite his tongue. The nurse should ensure that the client's airway is clear and patent.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.
