A nurse is assisting in the plan of care for a client who is receiving digoxin to treat heart failure. Which of the following actions should the nurse plan to take?

Measure the client's apical pulse rate for 30 seconds before administration.

Withhold the medication if the client's heart rate is above 100/min.

Instruct the client to eat foods that are low in potassium.

Monitor the client for nausea, vomiting, and yellow vision.

Answer and Explanation

The Correct Answer is D

A. The nurse should measure the apical pulse for a full minute (not 30 seconds) before administering digoxin. If the pulse is below 60 beats per minute, the medication should be withheld, making this option incomplete.
B. Digoxin should be withheld if the heart rate is below 60/min, not above 100/min. This statement does not reflect proper nursing protocol.
C. Clients taking digoxin should maintain adequate potassium levels, so advising low potassium intake is incorrect. Foods rich in potassium are encouraged.
D. Monitoring for symptoms such as nausea, vomiting, and yellow vision is essential, as these may indicate digoxin toxicity, making this option correct.

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Correct Answer is ["C","D","E"]

Explanation

A. Restraints should not be used routinely for clients with seizure disorders, as they can lead to injury and are not recommended for seizure management.
B. A bite stick is not recommended during a seizure because it can cause injury to the client’s teeth and jaw.
C. Keeping an oxygen setup at the bedside is essential to provide supplemental oxygen if the client experiences difficulty breathing during or after a seizure.
D. Elevating the side rails when the client is in bed helps prevent falls and injuries during a seizure, providing a safer environment.
E. A suction setup at the bedside is important to clear secretions and prevent aspiration during a seizure, especially if the client has impaired swallowing or is at risk for aspiration.

A. I’ll wear low-heeled shoes from now on. B. I’ll carry heavy objects close to my body. C. I’ll sit with my knees lower than my hips. D. I’ll do exercises that strengthen my abdominal muscles.

Correct Answer is C

Explanation

A. Wearing low-heeled shoes is advisable to promote better posture and alignment, so this statement is appropriate.
B. Carrying heavy objects close to the body is a recommended practice for preventing back injury, indicating correct understanding.
C. Sitting with knees lower than hips can lead to poor posture and increased strain on the lower back, indicating a need for further clarification. The correct position should have the knees level or slightly higher than the hips.
D. Strengthening abdominal muscles is beneficial for back support and injury prevention, indicating the client understands the concept.

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A nurse is assisting in the plan of care for a client who is receiving digoxin to treat heart failure. Which of the following actions should the nurse plan to take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is contributing to the plan of care for a client who has a seizure disorder. Which of the following interventions should the nurse include in the plan?

Correct Answer is ["C","D","E"]

Explanation

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Correct Answer is C

Explanation

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