A nurse is reinforcing discharge teaching with a client who will be starting a new prescription for digoxin. Which of the following instructions should the nurse include?

"Check your pulse for 1 minute before taking digoxin,"

"You should not take digoxin if you become pregnant."

"Limit your intake of foods high in potassium."

"Take your digoxin regularly every 6 hours."

Answer and Explanation

The Correct Answer is A

Digoxin is a cardiac glycoside used to improve myocardial contractility and control heart rate in certain cardiac conditions. Because it has a narrow therapeutic index, careful monitoring is essential to prevent toxicity, which can be life-threatening. Patient education focuses on safe administration, pulse assessment, recognition of toxicity signs, and maintaining appropriate electrolyte balance. Clients must understand when to hold the medication and when to seek medical attention.

Rationale:
A. Checking the pulse for 1 minute before taking Digoxin is correct because the medication should be withheld if the apical heart rate is below the prescribed threshold (usually <60 bpm in adults). This helps prevent bradycardia and digoxin toxicity. Accurate pulse assessment ensures safe administration and reduces risk of adverse cardiac effects.

B. Digoxin is not contraindicated in pregnancy, although it should be used cautiously and only when benefits outweigh risks. This statement is incorrect because it implies an absolute restriction that is not clinically accurate. Clinical decisions depend on maternal and fetal considerations rather than blanket avoidance.

C. Limiting potassium intake is incorrect because low potassium levels actually increase the risk of digoxin toxicity. Hypokalemia enhances digoxin binding to cardiac tissue, increasing its effects and toxicity risk. Patients are usually encouraged to maintain adequate potassium levels rather than restrict them.

D. Digoxin is not taken every 6 hours; it is typically administered once daily due to its long half-life. Frequent dosing increases the risk of accumulation and toxicity. Correct dosing schedules are essential to maintain therapeutic levels safely.

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Correct Answer is A

Explanation

Nursing care for clients with burn injuries such as those affecting the lower extremities requires strict infection control because damaged skin barriers significantly increase the risk of microbial invasion. Burn wounds are highly susceptible to contamination due to loss of protective epidermis and exposure of underlying tissues. Care for a client with a partial or full-thickness burn, as seen in Burn injury, focuses on aseptic technique, appropriate wound cleansing, and prevention of infection while promoting healing. Proper dressing technique is essential to reduce complications such as sepsis and delayed wound recovery.

Rationale:
A. Applying dressings with sterile gloves is correct because burn wounds require aseptic or sterile technique to minimize the risk of introducing pathogens into the damaged tissue. The absence of an intact skin barrier makes the client highly vulnerable to infection. Using sterile gloves during dressing application helps maintain a clean environment and supports optimal wound healing.

B. Using hydrogen peroxide for wound cleaning is inappropriate because it is cytotoxic to healthy tissue and can delay wound healing. Although it has antimicrobial properties, it damages fibroblasts and newly forming epithelial cells. Normal saline or prescribed wound cleansers are preferred for burn wound care.

C. Cleaning the most contaminated wounds first is incorrect because it increases the risk of cross-contamination to cleaner wound sites. Standard practice is to clean from the least contaminated area to the most contaminated area. This sequence helps prevent spread of microorganisms to vulnerable tissue.

D. Performing dressing changes every other day is not appropriate for most burn wounds, especially in the acute phase. Burn wounds often require more frequent assessment and dressing changes depending on exudate, infection risk, and type of dressing used. The frequency should be determined by provider orders and wound condition rather than a fixed schedule.

A. "I will wear a clean pair of cotton socks each day." B. "I can remove ingrown toenails at home as needed." C. "I need to use iodine to disinfect cuts on my feet." D. "I should soak my feet in warm water every morning."

Correct Answer is A

Explanation

Foot care is a critical component of self-management for clients with diabetes mellitus due to the risk of peripheral neuropathy, poor circulation, and delayed wound healing. These factors increase susceptibility to ulcers, infections, and potential limb complications. Proper hygiene, protective footwear, and daily inspection help prevent injury and promote early detection of skin breakdown. Nurses reinforce safe practices that reduce trauma and infection risk.

Rationale:
A. Wearing clean cotton socks daily helps maintain foot hygiene, reduce moisture buildup, and decrease friction that can lead to skin breakdown. Cotton allows better air circulation compared to synthetic materials, lowering the risk of fungal infections and irritation. In clients with conditions such as Type 2 diabetes mellitus, consistent protective foot care is essential to prevent ulcers and complications.

B. Removing ingrown toenails at home is unsafe because it can cause trauma, bleeding, and infection, especially in clients with reduced sensation and poor circulation. Any nail abnormalities should be managed by a healthcare professional or podiatrist. Self-removal increases the risk of serious complications.

C. Using iodine to disinfect foot cuts is not recommended because it can damage healthy tissue and delay wound healing. Modern wound care emphasizes gentle cleansing with mild soap and water or saline solutions. Harsh antiseptics may worsen tissue injury in diabetic wounds.

D. Soaking feet in warm water daily is discouraged because prolonged soaking can macerate the skin and increase the risk of breakdown and infection. Additionally, clients with neuropathy may not accurately sense water temperature, increasing the risk of burns. Short, gentle cleansing is preferred over soaking.

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A nurse is reinforcing discharge teaching with a client who will be starting a new prescription for digoxin. Which of the following instructions should the nurse include?

Nursing Test Bank

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Correct Answer is A

Explanation

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Correct Answer is A

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