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 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 client's oxygen saturation
The Correct Answer is C
A. Auscultate the client's lung sounds: While lung sounds are important to assess in clients with heart failure, auscultating lung sounds is not directly required before administering digoxin. The immediate concern with digoxin is its effect on heart rate and rhythm.
B. Check the client's weight: Monitoring weight is important in heart failure management to assess fluid retention, but weight measurement is not necessary immediately prior to administering a dose of digoxin.
C. Check the client's apical pulse: Before giving digoxin, it is critical to assess the client's apical pulse for one full minute. If the pulse is below a specified rate (60 beats/min for adults), the dose may need to be withheld and the provider notified due to the risk of digoxin-induced bradycardia.
D. Obtain the client's oxygen saturation: Oxygen saturation is important in evaluating respiratory function, but it is not a priority action before administering digoxin. The primary safety check is heart rate assessment.
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Related Questions
Correct Answer is B
Explanation
A. Reviewing client education: Reviewing education is often part of the termination phase, where teaching is reinforced and the nurse ensures the client understands care plans after the therapeutic relationship ends. It is not a primary focus during the working phase.
B. Identifying problem-solving skills: The working phase focuses on active problem-solving, setting goals, and implementing strategies to address the client's issues. This is when trust is established further, and the nurse and client collaborate on interventions and coping techniques to promote positive outcomes.
C. Summarizing the goals and objectives achieved: Summarizing achievements is part of the termination phase, when the nurse and client reflect on progress made. It helps bring closure to the relationship but does not belong to the working phase where the focus is still on active progress.
D. Specifying a contract: Specifying a contract is a task of the orientation phase, where the structure of the nurse-client relationship, roles, and expectations are defined. This lays the foundation before entering into the problem-solving focus of the working phase.
Correct Answer is B
Explanation
A: Image A shows the ankle area, which is an example of a hinge joint, not a ball and socket joint. Hinge joints allow movement in one plane, such as flexion and extension, similar to the motion of a door hinge. The ankle allows primarily up-and-down movement but does not rotate in multiple directions like a ball and socket joint would.
B: Image B shows the hip area, which represents a ball and socket joint. In a ball and socket joint, the round head of one bone fits into the cup-like socket of another bone, allowing movement in multiple directions. The hip and the shoulder are classic examples of ball and socket joints, permitting rotation, flexion, extension, abduction, and adduction.
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