The nurse is preparing to administer the client's morning dose of digoxin. Which action should the nurse take prior to administering the digoxin?

Verify that the urine output exceeds 30 mL per hour.

Check the client for signs of orthostatic hypotension.

Listen to the heart at the left 5th intercostal space.

Obtain a left radial pulse rate for a full 30 seconds.

Answer and Explanation

The Correct Answer is C

A. Verify that the urine output exceeds 30 mL per hour: Although adequate urine output is important for assessing overall kidney function, it is not directly related to the safe administration of digoxin. Digoxin administration is primarily concerned with heart rate and rhythm, not renal perfusion measures before dosing.

B. Check the client for signs of orthostatic hypotension: Orthostatic hypotension assessment is valuable in many clinical scenarios but is not the primary safety check required before administering digoxin. The priority is to ensure the heart rate is sufficient and regular, as digoxin can cause bradycardia.

C. Listen to the heart at the left 5th intercostal space: Digoxin can cause significant bradycardia and arrhythmias. Therefore, the nurse must auscultate the apical heart rate at the 5th intercostal space at the midclavicular line for a full minute to determine if the rate is within safe limits for administration, 60 – 100 beats per minute in adults.

D. Obtain a left radial pulse rate for a full 30 seconds: Checking a peripheral pulse for only 30 seconds is inadequate for evaluating the cardiac effects of digoxin. Peripheral pulses may be irregular or faint in cases of dysrhythmias, leading to inaccurate assessment compared to direct apical heart auscultation.

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Correct Answer is C

Explanation

A. Observe the client's mucous membranes: Monitoring mucous membranes is useful for assessing hydration status, but it is not the most critical intervention related to fentanyl use. The primary concern with opioid administration, especially fentanyl, is central nervous system and respiratory depression.

B. Auscultate the client's bowel sounds: Opioids like fentanyl can cause constipation due to slowed gastrointestinal motility. Although monitoring bowel sounds is important, it is a secondary concern compared to the immediate need to assess neurological and respiratory status.

C. Assess the client's level of consciousness (LOC): Fentanyl, a potent opioid, poses a significant risk for sedation and respiratory depression. Regular assessment of the client's LOC is essential to detect early signs of opioid toxicity, such as excessive drowsiness, confusion, or unresponsiveness, allowing for prompt intervention.

D. Record the client's urinary output: Opioids can lead to urinary retention, making output monitoring necessary, but it is not the most urgent priority. Ensuring the client's neurological status and breathing are stable takes precedence when administering potent opioids like fentanyl.

A. Assess for secondary Candida infection. B. Monitor for electrolyte imbalance. C. Administer sucralfate once a day, preferably at bedtime. D. Give sucralfate on an empty stomach.

Correct Answer is D

Explanation

A. Assess for secondary Candida infection: Sucralfate acts locally in the stomach to form a protective barrier over ulcers; it does not suppress the immune system or significantly alter the microbial flora. Therefore, it does not increase the risk of Candida infections, making this assessment unnecessary specifically for sucralfate therapy.

B. Monitor for electrolyte imbalance: Sucralfate does not typically cause major electrolyte disturbances. Unlike antacids, which may alter serum electrolytes, sucralfate's mechanism is physical coating of the gastric mucosa rather than altering gastric pH significantly or causing systemic absorption issues.

C. Administer sucralfate once a day, preferably at bedtime: Sucralfate is usually prescribed multiple times a day, typically four times daily, before meals and at bedtime. Administering it only once daily would not provide adequate mucosal protection necessary for ulcer healing.

D. Give sucralfate on an empty stomach: Sucralfate must be given on an empty stomach for optimal binding to the ulcer site. Food can interfere with its ability to adhere properly to the mucosal lining, reducing its effectiveness in promoting ulcer healing.

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The nurse is preparing to administer the client's morning dose of digoxin. Which action should the nurse take prior to administering the digoxin?

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