A nurse is preparing to administer digoxin to a client who has heart failure.
Before administering this medication, which of the following actions should the nurse take?

Check the client's blood pressure.

Measure the client's apical pulse.

Offer the client a light snack.

Weigh the client.

Answer and Explanation

The Correct Answer is B

Choice A rationale:

Checking the client's blood pressure is not the priority action when administering digoxin. Although monitoring blood pressure is essential in the overall care of a client with heart failure, the most critical parameter to assess before administering digoxin is the client's apical pulse.

Choice B rationale:

Measuring the client's apical pulse is the correct action to take before administering digoxin. Digoxin is a medication commonly prescribed for heart failure, and it has a narrow therapeutic range. It primarily works by increasing the force of the heart's contractions, and an excessively low heart rate (bradycardia) is a potential side effect of digoxin. Therefore, it is crucial to assess the client's apical pulse to ensure it is within the recommended range (usually above 60 beats per minute) before administering the medication. If the pulse rate is below the recommended range, the nurse should withhold the digoxin and notify the healthcare provider.

Choice C rationale:

Offering the client a light snack is not a necessary action before administering digoxin. While it is important to consider the client's dietary needs, it is not directly related to the administration of digoxin. However, if the client has nausea or vomiting, which can be a side effect of digoxin, a light snack might be offered after the medication.

Choice D rationale:

Weighing the client is not the immediate action to take before administering digoxin. Although daily weights can be important for assessing fluid balance in clients with heart failure, it is not the priority before administering digoxin. Monitoring the client's apical pulse is the most critical step in this context.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is A

Explanation

The correct answer is Choice A: Dull, aching calf pain.

Choice A rationale:

Dull, aching calf pain is a common symptom of deep vein thrombosis (DVT), which can occur postoperatively, especially after vascular surgery. This pain is often due to a blood clot forming in the deep veins of the leg.

Choice B rationale:

Positive Kernig's sign is associated with meningitis and not typically related to thrombus formation.

Choice C rationale:

Soft, pliable calf muscle is not indicative of a thrombus. A thrombus would more likely cause tenderness and swelling.

Choice D rationale:

Positive Homan's sign (pain in the calf upon dorsiflexion of the foot) can be an indicator of DVT, but it is less reliable than dull, aching calf pain.

A. Metabolic acidosis. B. Respiratory alkalosis. C. Metabolic alkalosis. D. Respiratory acidosis.

Correct Answer is D

Explanation

Choice A rationale:

A respiratory rate of 9/min and shallow respirations are indicative of hypoventilation, which can lead to an accumulation of carbon dioxide (CO2) in the blood. This condition results in respiratory acidosis (Choice D). In respiratory acidosis, the arterial pH is decreased (acidic) while the PaCO2 (partial pressure of carbon dioxide) is elevated.

Choice B rationale:

Respiratory alkalosis (Choice B) is characterized by a low PaCO2 and an elevated pH due to hyperventilation. Shallow respirations and a respiratory rate of 9/min do not align with this condition, as it typically involves rapid and deep breathing.

Choice C rationale:

Metabolic alkalosis (Choice C) results from a primary excess of bicarbonate (HCO3-) in the blood and is not associated with the given respiratory patterns. Shallow respirations and a low respiratory rate are more likely to lead to an accumulation of CO2, causing respiratory acidosis (Choice D).

Choice D rationale:

The correct answer is choice D. Shallow respirations and a respiratory rate of 9/min indicate hypoventilation, leading to an accumulation of CO2 in the blood. This condition results in respiratory acidosis, where the arterial pH is decreased. The body's compensatory response is to retain bicarbonate to normalize pH, but this can result in an elevated HCO3- level. The primary acid-base imbalance in this case is respiratory acidosis. .

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse is preparing to administer digoxin to a client who has heart failure.Before administering this medication, which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is postoperative following vascular surgery. Which of the following manifestations should indicate to the nurse that the client has developed a thrombus?

Correct Answer is A

Explanation

A nurse is collecting data from a client who has shallow respirations and a respiratory rate of 9/min.Which of the following acid-base imbalances should the nurse expect?

Correct Answer is D

Explanation

A nurse is preparing to administer digoxin to a client who has left-sided heart failure.Which of the following clinical manifestations should the nurse expect to see in this client? (Select all that apply.).

A nurse is preparing to administer digoxin to a client who has heart failure.Before administering this medication, which of the following actions should the nurse take?

A nurse is caring for a client who has asthma. The client asks the nurse how albuterol helps his breathing. Which of the following information should the nurse include in the response? (Select all that apply.).

A nurse is measuring the vital signs of a client he suspects has hypovolemic shock.Which of the following findings should the nurse expect?

A nurse is collecting data from a client who has left-sided heart failure. Which of the following findings should the nurse expect?

A nurse is reinforcing teaching with a client who is taking hydrochlorothiazide.Which of the following information should the nurse include in the teaching?

A nurse in a provider's office is reviewing the laboratory results of four clients who take digoxin. Which of the following clients is at risk for developing digoxin toxicity?

A nurse is reviewing the arterial blood gas (ABG) results of a client. The client's ABGs are:. A. pH: 7.6. B. PaCO2: 40 mm Hg. C. HCO3: 32 mEq/L. Which of the following acid-base conditions should the nurse identify the client is experiencing?

A nurse is preparing to administer digoxin to a client who has heart failure.
Before administering this medication, which of the following actions should the nurse take?