A nurse is preparing to administer digoxin to a pediatric client who has heart failure. Which of the following actions is appropriate?
Instructing the client to eat foods that are low in potassium.
Repeat the dose if the client spits it out.
Measuring apical pulse rate for 30 seconds before administration.
Evaluating the client for nausea, vomiting, and anorexia.
The Correct Answer is C
A. Clients on digoxin should actually have an adequate intake of potassium, as low potassium levels can increase the risk of digoxin toxicity.
B. If a pediatric client spits out digoxin, the dose should not be repeated automatically; instead, the nurse should assess the situation and follow the facility's protocol regarding missed doses.
C. Measuring the apical pulse for one full minute before administering digoxin is critical; if the pulse is below the established threshold (usually <60 bpm for children), the medication should be held and the provider notified.
D. While evaluating for nausea, vomiting, and anorexia is important, it is not an appropriate immediate action before administering the medication. The priority action is to assess the apical pulse.
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Related Questions
Correct Answer is C
Explanation
A. Taking ferrous sulfate between meals may actually help reduce the risk of constipation, but this is not the primary reason for timing.
B. Taking the medication with food does not typically increase the risk of esophagitis; rather, it can decrease the absorption of iron.
C. Taking ferrous sulfate between meals allows for optimal absorption of iron, as food can interfere with its absorption. This response accurately explains the rationale for the timing of the medication.
D. While it is true that some patients may experience nausea when taking iron supplements with food, the primary reason for taking it between meals is to enhance absorption rather than to prevent nausea.
Correct Answer is C
Explanation
A. Encouraging the adolescent to spend more time alone may reinforce their withdrawal and does not promote social interaction or engagement.
B. Assigning the adolescent as a leader may increase anxiety and exacerbate their withdrawal rather than encourage socialization.
C. One-on-one counseling can provide a safe space for the adolescent to express feelings and explore the reasons for their withdrawal, which is a supportive and therapeutic intervention.
D. Focusing solely on academic achievements may lead to further isolation and does not address the need for social skills development and peer interaction.
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