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 A

Explanation

A. Rigid expectations of behavior: Perpetrators of child abuse often have unrealistic and rigid expectations of children’s behavior. When children do not meet these expectations, it can lead to frustration, anger, and abusive responses from the caregiver.

B. Self-blame for financial problems: While financial stress can be a risk factor for family dysfunction, self-blame alone is not a recognized direct characteristic of child abuse perpetrators. Abusive behavior is more often linked to blaming others and lack of coping skills.

C. Laissez-faire leadership style: A laissez-faire leadership style involves being hands-off or permissive, which is not typically associated with abusive behaviors. Abusers are often controlling and overly strict, not permissive.

D. High self-esteem: High self-esteem is generally associated with healthy interpersonal behavior. Low self-esteem, poor coping mechanisms, and unresolved personal trauma are more commonly seen in those who commit child abuse.

A. Erythema B. Blood C. Edema D. Pruritus

Correct Answer is C

Explanation

A. Erythema: Erythema, or redness, is more commonly associated with phlebitis, an inflammation of the vein, rather than infiltration. While some redness may occur, it is not the primary or expected finding when infiltration is present.

B. Blood: The presence of blood at the insertion site may indicate a bleeding or hematoma issue but is not a typical sign of infiltration. Infiltration involves fluid, usually IV solution, leaking into surrounding tissue, not blood leaking out of the vein.

C. Edema: Edema at the insertion site is a hallmark sign of infiltration. When IV fluid escapes into the surrounding tissue instead of remaining in the vein, it causes localized swelling, coolness, and often discomfort or tightness around the insertion area.

D. Pruritus: Pruritus, or itching, is not a typical manifestation of infiltration. It may be seen with allergic reactions to IV medications or materials, but infiltration primarily presents with swelling, coolness, and sometimes blanching of the skin.

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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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