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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. It is not permissible because the provider should disclose laboratory results or findings to a client:
While it is true that the provider should disclose laboratory results or findings to the client, the nurse, in this case, should not be accessing the information on behalf of the sibling without proper authorization.
B. It is permissible because the client's sibling made the request:
Even if the sibling made the request, accessing a client's health information without proper authorization is a violation of privacy and confidentiality.
C. It is permissible because the sibling has paid for the service:
Payment for services does not automatically grant access to health information. Protected health information (PHI) is subject to privacy laws, and access should be granted only to those authorized to receive it.
D. It is not permissible because there is no nurse-client relationship between the sibling and nurse:
This is the correct explanation. The nurse should not access a client's health information, even if it is a family member, without proper authorization. The absence of a nurse-client relationship with the sibling does not justify accessing the client's health information.
Correct Answer is ["2"]
Explanation
To calculate the dosage of amoxicillin, the nurse needs to divide the prescribed dose by the available dose and multiply by one tablet. In this case, the prescribed dose is 500 mg and the available dose is 250 mg. Therefore, the nurse should administer:
(500 mg / 250 mg) x 1 tablet = 2 tablets
The nurse should document the administration of amoxicillin in the patient's chart and monitor for any adverse reactions or allergies.
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