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.

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Correct Answer is C

Explanation

Choice A rationale:

Hypertension is not typically associated with low calcium levels. Hypertension is more commonly linked to issues with blood pressure regulation and not calcium levels.

Choice B rationale:

Diaphoresis (excessive sweating) is not a direct symptom of low calcium levels. Low calcium can lead to muscle cramps and tetany, but not sweating.

Choice C rationale:

Muscle tetany is a common manifestation of low calcium levels (hypocalcemia). It results from increased neuromuscular excitability, causing muscle spasms and contractions. A calcium level of 7 mg/dL is below the normal range, and this client is at risk for muscle tetany.

Choice D rationale:

Increased thirst is not a typical symptom of low calcium levels. Symptoms of hypocalcemia are primarily related to neuromuscular and cardiovascular changes, such as muscle tetany and cardiac arrhythmias.

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

Correct Answer is A

Explanation

Choice A rationale:

Metabolic alkalosis Metabolic alkalosis is characterized by an elevated pH (above the normal range of 7.35-7.45) and an increased bicarbonate (HCO3) level (above the normal range of 22-28 mEq/L). In this case, the client's pH of 7.6 and HCO3 level of 32 mEq/L indicate a primary metabolic alkalosis. It can be caused by excessive bicarbonate intake, loss of acid (as in vomiting or excessive diuretic use), or other factors that result in an excess of bicarbonate in the body. The PaCO2 level is within the normal range (35-45 mm Hg), which is consistent with compensatory hypoventilation seen in metabolic alkalosis.

Choice B rationale:

Metabolic acidosis Metabolic acidosis is characterized by a decreased pH and bicarbonate level. The client's ABG results do not align with metabolic acidosis. In this case, the pH is elevated, and the bicarbonate level is above the normal range.

Choice C rationale:

Respiratory alkalosis Respiratory alkalosis is characterized by an elevated pH and decreased PaCO2. The client's ABG results show a normal PaCO2 of 40 mm Hg, which does not align with respiratory alkalosis. In respiratory alkalosis, you would typically see a lower PaCO2.

Choice D rationale:

Respiratory acidosis Respiratory acidosis is characterized by a decreased pH and elevated PaCO2. The client's ABG results do not align with respiratory acidosis. In this case, the PaCO2 is within the normal range, and the pH is elevated, which is not indicative of respiratory acidosis.

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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?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is A

Explanation

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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?