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.

Answer and Explanation

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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Correct Answer is ["C","D","E"]

Explanation

A. A client who has had prolonged diarrhea:

Prolonged diarrhea is not typically associated with an increased risk of aspiration during eating.

B. A client who has lactose intolerance:

Lactose intolerance primarily affects the ability to digest lactose-containing foods and does not directly increase the risk of aspiration.

C. A client who has had radiation therapy for head and neck cancer:

Radiation therapy to the head and neck can cause damage to the structures involved in swallowing, increasing the risk of aspiration.

D. A client who has had a stroke:

Stroke can affect the coordination of swallowing muscles, leading to dysphagia (difficulty swallowing) and an increased risk of aspiration.

E. A client who is 4 hr postoperative following a leg amputation under general anesthesia:

Postoperative clients under general anesthesia may experience impaired protective airway reflexes, making them prone to aspiration. It's important to monitor these clients closely during the initial recovery period.

A. "I will keep my walker at the end of my bed." B. "I will place an area rug at the entry of my bathroom." C. "I will keep the fluorescent ceiling light on in my room at night." D. "I will place a bath seat in my shower to use when I bathe." E. Check the tops of his ears regularly for skin breakdown.

Correct Answer is D

Explanation

A. "I will keep my walker at the end of my bed":

While keeping the walker at the end of the bed may be convenient, it is not a safety measure in itself. It's important for the client to use the walker as needed for support and stability, especially during ambulation.

B. "I will place an area rug at the entry of my bathroom":

Placing area rugs can be a fall hazard, as they may cause tripping. It is generally recommended to have non-slip surfaces, especially in areas prone to moisture like the bathroom.

C. "I will keep the fluorescent ceiling light on in my room at night":

While having adequate lighting is important for preventing falls, leaving a fluorescent ceiling light on all night may not be necessary. Using night lights or low-intensity lighting may be more appropriate to prevent disruption of sleep.

D. "I will place a bath seat in my shower to use when I bathe":

This is the correct statement. Using a bath seat in the shower provides stability and reduces the risk of slipping and falling while bathing. It is a proactive measure to enhance safety in the bathroom.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a group of clients. Which of the following clients should the nurse identify as having an increased risk for aspiration while eating? (Select all that apply.)

Correct Answer is ["C","D","E"]

Explanation

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Correct Answer is D

Explanation

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