A nurse is caring for a client with a congenital heart disease who is prescribed digoxin. The nurse should instruct the client to report which symptom immediately?
Weight gain of 1 pound in a week.
Heart rate below 100 beats per minute.
Occasional episodes of diarrhea.
Mild swelling of the ankles after activity.
The Correct Answer is A
A) The answer is A. Weight gain of 1 pound in a week can indicate fluid retention, which may be a sign of digoxin toxicity. The nurse should instruct the client to report this symptom immediately to prevent further complications.
B) Incorrect. A heart rate below 100 beats per minute is within the normal range for most clients. A lower heart rate is often expected in clients taking digoxin, and it does not require immediate reporting unless accompanied by other concerning symptoms.
C) Incorrect. Occasional episodes of diarrhea are common side effects of digoxin. The client should report persistent or severe diarrhea, but occasional episodes may not be a cause for immediate concern.
D) Incorrect. Mild swelling of the ankles after activity is not directly related to digoxin use. The nurse should monitor the client's ankles for any worsening swelling, but it does not require immediate reporting unless accompanied by other concerning symptoms.
The answer is A
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Related Questions
Correct Answer is A
Explanation
A) Correct answer. Weight gain and edema in the lower extremities can be signs of worsening heart failure in children with congenital heart defects. Fluid retention occurs due to the heart's inability to effectively pump blood, leading to fluid accumulation in the body.
B) This option is incorrect. While decreased heart rate and blood pressure within the normal range may be indicative of stable heart function, they are not specific indicators of worsening heart failure.
C) This option is incorrect. Improved appetite and increased physical activity level are positive indicators but do not specifically reflect the child's heart failure status.
D) This option is incorrect. Resolution of cyanosis and pink coloration of the lips and nail beds are positive signs of improved oxygenation and may indicate effective management of the heart defect but not the potential worsening of heart failure.
Correct Answer is A
Explanation
A) The answer is A. Before administering digoxin, the nurse should check the infant's apical heart rate for a full minute. Digoxin is a medication used to improve cardiac contractility, and knowing the heart rate helps ensure the medication is given safely and at the correct dose.
B) Incorrect. While measuring blood pressure is essential in some cases, it is not the priority action before administering digoxin.
C) Incorrect. Assessing capillary refill time is an important part of the overall assessment, but it is not the priority action before giving digoxin.
D) Incorrect. While observing for respiratory distress is crucial, it is not the priority action in this specific scenario of preparing to administer digoxin. Checking the heart rate takes precedence.
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