A nurse is preparing to administer a dose of digoxin to a client who is experiencing heart failure. Which of the following actions should the nurse take prior to administering this medication?
Auscultate the client's lung sounds.
Check the client's weight
Check the client's apical pulse
Obtain the clients oxygen saturation
The Correct Answer is C
A. Auscultate the client's lung sounds: While assessing lung sounds is an important part of the overall assessment for a client with heart failure (to check for pulmonary edema/crackles), it is not a specific requirement for the administration of digoxin. It helps evaluate the effectiveness of the treatment over time but does not determine if the current dose is safe to give.
B. Check the client's weight: Daily weights are essential for monitoring fluid volume status in heart failure patients. However, like lung sounds, this is an assessment of the disease progression rather than a safety check for the medication's immediate effect on the heart's electrical system.
C. Check the client's apical pulse: Digoxin can cause bradycardia and other arrhythmias. The nurse must assess the apical pulse for a full minute before administration and withhold the medication if the rate is below the provider’s prescribed parameters (commonly <60 bpm in adults).
D. Obtain the client's oxygen saturation: Oxygen saturation provides information about respiratory status but does not directly influence the decision to administer digoxin.
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Related Questions
Correct Answer is D
Explanation
A. Social withdrawal: Social withdrawal is common in Alzheimer's disease and may indicate depression or disease progression. While important to address, it does not pose an immediate safety risk.
B. Inability to remember their partner’s name: Memory loss is a hallmark of Alzheimer's disease. Forgetting familiar names requires monitoring and supportive strategies but is not an urgent safety concern.
C. Difficulty articulating words: Language difficulties can affect communication and quality of life, but they do not immediately endanger the client. Interventions focus on speech therapy and alternative communication methods.
D. Wandering outside at night: Wandering exposes the client to hazards such as getting lost, traffic accidents, or injury, making it a priority safety concern. Immediate intervention is necessary to protect the client and prevent harm.
Correct Answer is A
Explanation
A. "I will give this medication to my child once daily in the evening.": Montelukast is a leukotriene receptor antagonist taken once daily, usually in the evening, to prevent asthma symptoms. Administering it at the correct time supports consistent therapeutic levels and effective long-term asthma control.
B. "I will give this medication to my child every 2 hours if he is wheezing": Montelukast is not a rescue medication and should not be administered for acute asthma attacks. Using it every 2 hours for wheezing is inappropriate and could delay effective emergency treatment.
C. "It takes 2 months of scheduled use before this medication is effective.": Montelukast generally begins working within a few days to weeks, not two months. Delaying assessment of effectiveness for two months could lead to uncontrolled asthma symptoms.
D. "I can stop giving my child this medication if he is taking a steroid.": Montelukast can be used alongside inhaled or oral steroids to manage asthma and should not be discontinued without consulting the healthcare provider. Stopping it abruptly may reduce asthma control.
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