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. "You will also find he will want to wear girls' clothes, including dresses, as well.": This response incorrectly assumes that playing with dolls predicts future behavior regarding gender expression, which is not accurate. It also may cause unnecessary worry for the parent.
B. "Gender identity is generally not established until the child is around five years old.": While partially true, this response does not directly address the parent's concern about the current behavior. It misses the opportunity to explain that imitating caregiving is a normal developmental stage.
C. "At two years of age, toddlers often engage in play that imitates adult actions.": This response correctly explains that toddlers naturally mimic the behavior they observe in adults, including caregiving activities, without it indicating future gender identity. Play is a normal part of development at this age.
D. "When a male toddler chooses to play with dolls, it is an indication he will later identify as a female.": This statement is inaccurate and misleading. A toddler’s choice of toys reflects curiosity and imitation, not a prediction of future gender identity or roles.
Correct Answer is ["C","D","E"]
Explanation
A. "The client in room 204 received some pain medicine earlier today": This statement is vague and nonspecific, lacking essential information such as the type of pain medication, dose, timing, and client response. Change-of-shift reports require clear, detailed, and actionable information to ensure continuity of care.
B. "The client in room 205 has had several visitors today": Information about visitors is generally not relevant to clinical care unless it impacts the client's condition. Reporting should focus on clinical updates, treatments, medications, or changes in the client’s status that require attention from the incoming nurse.
C. "The client in room 204 has a new prescription for gentamicin": This statement provides important clinical information regarding a change in the medication regimen. It alerts the next nurse to monitor for potential side effects, such as nephrotoxicity or ototoxicity, associated with gentamicin use.
D. "The client in room 203 will undergo surgery at 0900 tomorrow": Communicating scheduled surgeries is critical for planning preoperative care, ensuring that preoperative checklists are completed, and managing fasting requirements. It allows the next shift to prepare the client properly and coordinate care.
E. "The client in room 205 is scheduled for a dressing change at 1800": Including scheduled treatments like dressing changes ensures that important interventions are completed on time. It also helps the incoming nurse prioritize tasks and manage the shift effectively to meet the client’s care needs.
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