The nurse receives a healthcare provider order for a client that states, "Digoxin 25 mg IV STAT" What action should the nurse take first?
Clarity the order with the healthcare provider
Listen to the apical pulse for one minute
Obtain a current blood pressure reading
Ensure the client's IV site is patent
The Correct Answer is A
A. Clarify the order with the healthcare provider: The order for digoxin 25 mg IV is dangerously high and far exceeds the usual therapeutic dose (typically micrograms, not milligrams). The nurse must verify the order before administration to prevent life-threatening toxicity.
B. Listen to the apical pulse for one minute: While assessing the apical pulse is essential before administering digoxin to check for bradycardia, verifying the unusually high dose takes priority to ensure client safety.
C. Obtain a current blood pressure reading: Monitoring blood pressure is important because digoxin can affect cardiac output, but confirming the safety of the ordered dose comes before vital sign assessment in this scenario.
D. Ensure the client's IV site is patent: Ensuring IV patency is necessary for safe medication administration, but it is secondary to clarifying an unsafe order to prevent immediate harm to the client.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Clarify the order with the healthcare provider: The order for digoxin 25 mg IV is dangerously high and far exceeds the usual therapeutic dose (typically micrograms, not milligrams). The nurse must verify the order before administration to prevent life-threatening toxicity.
B. Listen to the apical pulse for one minute: While assessing the apical pulse is essential before administering digoxin to check for bradycardia, verifying the unusually high dose takes priority to ensure client safety.
C. Obtain a current blood pressure reading: Monitoring blood pressure is important because digoxin can affect cardiac output, but confirming the safety of the ordered dose comes before vital sign assessment in this scenario.
D. Ensure the client's IV site is patent: Ensuring IV patency is necessary for safe medication administration, but it is secondary to clarifying an unsafe order to prevent immediate harm to the client.
Correct Answer is B
Explanation
A. Chicken breast: Chicken breast is low in vitamin K and does not significantly affect warfarin’s anticoagulant effect. Regular consumption does not require adjustment in warfarin dosing, so it is generally safe to eat without major concern.
B. Brussels sprouts: Brussels sprouts are high in vitamin K, which can interfere with warfarin’s effectiveness by promoting clotting. Sudden increases or decreases in intake can cause fluctuations in INR levels, making it essential for clients to maintain a consistent intake.
C. Whole milk: Whole milk contains minimal vitamin K and does not significantly impact warfarin therapy. While it provides nutrients, it does not pose a risk for altering anticoagulation and does not require dietary restrictions for warfarin management.
D. Salami: Salami is high in sodium and fat but low in vitamin K, so it does not directly affect warfarin activity. While clients should monitor overall diet for cardiovascular health, salami intake does not necessitate strict control for anticoagulation purposes.
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