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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. A client who is receiving an enteral tube feeding and has a blood glucose level of 155 mg/dL (74 to 106 mg/dL): A mildly elevated blood glucose level is not immediately life-threatening and can be managed after addressing more urgent issues. This client is stable at the moment.
B. A client who has a spinal cord injury and needs a dressing change: While important for preventing infection, a scheduled dressing change is not an immediate threat to the client’s life or health and can be safely performed after more urgent concerns are addressed.
C. A client who has a temperature of 38.4° C (101.1° F) and appears confused: Fever and new-onset confusion suggest a possible infection, such as sepsis or urinary tract infection, especially in older adults. This situation indicates a potential life-threatening condition and requires immediate assessment and intervention.
D. A client who had a hip arthroplasty and is requesting pain medication: Managing pain is important, but it is not immediately life-threatening. After addressing the client with fever and confusion, attending to the client's pain needs would be appropriate.
Correct Answer is A
Explanation
A. Monitor the client for 1 hr after meals: Clients with anorexia nervosa are at high risk for purging behaviors such as vomiting or excessive exercise after meals. Monitoring them for at least 1 hour post-meal helps prevent these behaviors and supports the therapeutic goal of safe weight restoration.
B. Allow the client 2 hr to finish meals: Allowing 2 hours to complete meals is too long and may encourage food avoidance behaviors. Structured meal times with limits (usually around 30 to 45 minutes) are important to establish routine eating habits and prevent manipulation of eating times.
C. Weigh the client every 2 days: Clients with anorexia nervosa are typically weighed daily, often at the same time each morning, to closely monitor weight trends and assess the effectiveness of the treatment plan. Monitoring every 2 days may miss rapid changes that require immediate intervention.
D. Check the client's vital signs two times per week: Vital signs should be checked daily in clients with anorexia nervosa, especially early in treatment, because of the risks of bradycardia, hypotension, and hypothermia. Infrequent monitoring can delay recognition of life-threatening physiological instability.
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