A nurse is caring for a client who has heart failure and has been taking digoxin 0.25 mg daily. The client refuses breakfast and reports nausea. Which of the following actions should the nurse take first?
Request a dietary 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
A. Request a dietary consult:
While dietary concerns may be addressed, checking vital signs is the priority when a client reports nausea, especially in the context of medication administration.
B. Check the client's vital signs:
This is the correct action. Nausea can be a symptom of digoxin toxicity. Checking vital signs, especially assessing for changes in heart rate, is crucial in determining whether the client is experiencing adverse effects of digoxin.
C. Request an order for an antiemetic:
Administering an antiemetic may be considered later, but the first priority is to assess the client's vital signs and determine if the nausea is related to digoxin toxicity.
D. Suggest that the client rests before eating the meal:
Resting before eating may be helpful for nausea, but the priority is to assess the client's vital signs and determine the cause of the nausea, especially in the context of digoxin use.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["15"]
Explanation
To calculate the dose of amantadine for a client with parkinsonism, the nurse needs to use the formula: Dose (mL) = Ordered dose (mg) / Available dose (mg/mL) x Available volume (mL).
In this case, the ordered dose is 150 mg, the available dose is 50 mg/5 mL, and the available volume is 5 mL.
Plugging these values into the formula, we get: Dose (mL) = 150 mg / (50 mg/5 mL) x 5 mL.
Simplifying, we get: Dose (mL) = 15 mL.
Therefore, the nurse should administer 15 mL of amantadine oral solution to the client.
Correct Answer is C
Explanation
A. Assist a client to eat who has difficulty seeing the foods on the tray.
Assisting a client with eating is a routine task that an AP can perform, especially when the client has difficulty with vision.
B. Provide postmortem care for a client who has died.
Postmortem care involves preparing the body of a deceased client. While it requires sensitivity, it is a task that can be appropriately delegated to assistive personnel.
C. Observe a confused surgical client who has multiple tubes.
Observing a confused client with multiple tubes requires a level of assessment and decision-making that goes beyond the scope of practice for an assistive personnel (AP). This task involves monitoring the client's condition, recognizing changes, and responding appropriately, which should be performed by a licensed nurse.
D. Deliver a client's urine specimen to the laboratory.
Transporting a urine specimen to the laboratory is a task that an assistive personnel can perform, as it does not involve interpretation or assessment of the specimen.
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