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

Answer and Explanation

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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Correct Answer is D

Explanation

A. Active movement is present: The presence of active movement in the fingers and toes of the affected arm indicates that nerve and muscle function are intact, which is a positive finding. It indicates there is no impairment in function of the affected arm.

B. Pain is 4 on scale of 0 to 10: A pain level of 4 is moderate pain and might be expected after a fracture. As long as pain is being managed appropriately with prescribed medications and no other concerning symptoms are present, it does not necessarily require immediate reporting.

C. Capillary refill is less than 2 seconds: A capillary refill time of less than 2 seconds is normal. This suggests good blood flow to the affected arm and is not an issue that needs reporting.

D. Skin is cool to the touch: A cool skin temperature on the affected arm could indicate impaired circulation, possibly due to swelling or tightness of the cast, which could lead to compartment syndrome—a serious condition that requires immediate intervention. Therefore, this finding should be reported to the provider immediately.

A. A nursing colleague documenting vitals in the electronic medical record (EMR) of a client that the colleague is caring for. B. A nursing colleague printing material that does not obtain identifiable information from a client's electronic medical record (EMR) for professional use. C. A nursing colleague discussing a client's diagnosis with another staff member on the unit who is not involved in the client's care. D. A nursing colleague discussing a client's treatment plan with another nurse on the unit as part of the end-of-shift handoff report.

Correct Answer is C

Explanation

A. A nursing colleague documenting vitals in the electronic medical record (EMR) of a client that the colleague is caring for: This is appropriate documentation practice. Nurses are responsible for documenting client information in the EMR when they provide direct care, ensuring accurate and timely records.

B. A nursing colleague printing material that does not contain identifiable information from a client's electronic medical record (EMR) for professional use: If no identifiable client information is included, and it is for professional, educational, or training purposes, this action is acceptable and does not violate confidentiality.

C. A nursing colleague discussing a client's diagnosis with another staff member on the unit who is not involved in the client's care: Discussing confidential client information with staff not directly involved in the client's care is a violation of HIPAA and breaches client privacy. Only staff responsible for the client's care should access or discuss their health information.

D. A nursing colleague discussing a client's treatment plan with another nurse on the unit as part of the end-of-shift handoff report: This is appropriate because handoff reports ensure continuity of care. Discussing necessary client information with the next caregiver is essential for safe, effective client management.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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