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 B

Explanation

A. Insomnia may occur while taking the medication: St. John's wort can increase central nervous system stimulation, leading to side effects like insomnia, restlessness, and anxiety. Educating the client that sleep disturbances may occur is appropriate and consistent with known herb effects.

B. Another form of contraception is not needed: St. John's wort can induce cytochrome P450 enzymes, leading to faster metabolism and reduced effectiveness of hormonal contraceptives like birth control pills. Clients must be advised to use an additional non-hormonal contraceptive method to prevent unintended pregnancy.

C. Hard candy can be used for a dry mouth: Dry mouth is a recognized side effect of St. John's wort. Sucking on hard candy, increasing oral hydration, or chewing sugarless gum are appropriate and effective ways to manage this discomfort.

D. Sensitivity to the sun can develop: Photosensitivity is a well-documented adverse effect of St. John's wort. Clients should be instructed to use sunscreen, wear protective clothing, and limit sun exposure to prevent sunburns or skin reactions.

A. Determine if the medication is being taken correctly. B. Schedule an appointment for evaluation by the healthcare provider. C. Advise stopping the medication until the unpleasant effects wear off. D. Provide instructions in managing these side effects.

Correct Answer is D

Explanation

A. Determine if the medication is being taken correctly: While verifying correct usage is always important, the symptoms described dry mouth and sensitivity to bright light are expected side effects of dicyclomine and are not typically caused by improper administration.

B. Schedule an appointment for evaluation by the healthcare provider: Mild anticholinergic side effects like dry mouth and photosensitivity do not usually require urgent medical evaluation unless they become severe or are accompanied by other concerning symptoms.

C. Advise stopping the medication until the unpleasant effects wear off: Abruptly stopping medications, especially those for chronic conditions like IBS, is generally not recommended without consulting the healthcare provider. It can lead to a return of symptoms or other adverse effects. The nurse should focus on managing the side effects so the client can continue the prescribed treatment.

D. Provide instructions in managing these side effects: Dry mouth can be managed by sipping water, using sugar-free gum, or using saliva substitutes. Photosensitivity can be addressed with sunglasses and protective clothing. Educating the client on managing these effects supports continued therapy and improves comfort.

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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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Naxlex Comprehensive Predictor Exams

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