A nurse is preparing to administer digoxin orally to a client. Identify the sequence of steps the nurse should take (Move the steps into the box on the right, placing them in the order of performance. Use all the steps)
Remove the medication from the dispensing system.
Compare the client’s wristband to the medication administration record.
Document administration of the medication.
Open the medication package.
Obtain the client’s apical heart rate.
The Correct Answer is E, A, B, D, C
Before administering digoxin, the nurse should check the patient's apical heart rate. If the heart rate is below 60 beats per minute for an adult, or below the prescribed limit for a child, the nurse should hold the medication and notify the healthcare provider. This is the first step because the nurse needs to have the medication in hand before proceeding with the other steps. This step is crucial to ensure that the right medication is being given to the right patient. It's a part of the "five rights" of medication administration: right patient, right medication, right dose, right route, and right time. Once the nurse has confirmed the patient's identity and heart rate, the next step is to open the medication package. After administering the medication, the nurse should document it in the patient's medical record. This is important for maintaining an accurate record of the patient's medication history.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
C.Although postoperative pain can cause a similar presentation, pain management is not the priority intervention.
D. The client's vital signs of tachycardia, tachypnea, and elevated blood pressure suggest potential respiratory distress or inadequate oxygenation following the thoracotomy. Applying oxygen at a high flow rate via a non-rebreather mask can help improve oxygenation and support the client's respiratory function.
Correct Answer is D
Explanation
Weakened cough effort can lead to ineffective airway clearance and increase the risk of aspiration pneumonia, a common complication in ALS due to bulbar muscle involvement. Aspiration pneumonia is a serious and potentially life-threatening condition that requires immediate intervention
A This symptom can be distressing for the client and may impact their quality of life. While it should be addressed and managed, it does not pose an immediate threat to the client's physical health.
B Asymmetrical weakness is a hallmark feature of ALS, where muscle weakness typically begins in one region of the body and gradually spreads to other areas. While it signifies disease progression and may impact the client's mobility and function, it does not necessarily require immediate intervention.
C Anxiety is a common emotional response in clients with ALS, especially as the disease progresses and the client faces physical decline and uncertainty about the future. While it is important to address the client's emotional well-being and provide support, increasing anxiety does not usually warrant immediate intervention.
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