A nurse is caring for a client diagnosed with congestive heart failure and is taking digoxin daily. The client refused breakfast and is complaining of nausea and weakness. Which of the following actions should the nurse take first?

Check an apical pulse

Request a dietitian consult.

Request an order for an antiemetic

Suggest that the client rests before eating the meal

Answer and Explanation

The Correct Answer is A

A. Check an apical pulse: Digoxin is known to cause toxicity, which can manifest as nausea, weakness, and anorexia. Bradycardia is a common sign of digoxin toxicity. Therefore, the nurse's first action should be to assess the client's apical pulse rate to determine if there are any signs of bradycardia, which could indicate digoxin toxicity.

B. Request a dietitian consult: While nutrition is important, the client's symptoms of nausea and weakness need immediate attention to rule out digoxin toxicity before considering dietary interventions.

C. Request an order for an antiemetic: Administering an antiemetic may be indicated if the client is experiencing nausea, but it's crucial to assess for digoxin toxicity first, as antiemetics may mask symptoms of toxicity.

D. Suggest that the client rests before eating the meal: Rest may be beneficial for the client, but addressing the potential cause of the symptoms, such as digoxin toxicity, takes priority

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Correct Answer is B

Explanation

A. Prolonged P-R interval: A prolonged P-R interval may indicate an atrioventricular (AV) block or conduction delay, but it is not specifically associated with hyperkalemia.

B. Peaked T waves: Peaked T waves are a classic EKG finding in hyperkalemia. Hyperkalemia can affect cardiac repolarization, leading to tall, peaked T waves on the EKG.

C. Elevated ST segment: An elevated ST segment may indicate myocardial injury or ischemia but is not typically associated with hyperkalemia.

D. Inverted P wave: An inverted P wave may indicate atrial enlargement or conduction abnormalities but is not specifically associated with hyperkalemia.

A. "I will be placing electrodes on your breasts." B. "I will lower the head of your bed so you can lie flat." C. "Relax and try not to move or speak once I have attached the gel pads." D. "Try to hold your breath until this procedure is complete."

Correct Answer is C

Explanation

A. "I will be placing electrodes on your breasts": This statement is incorrect and may cause unnecessary concern or discomfort for the client. Electrodes for a 12-lead electrocardiogram are typically placed on the chest, not the breasts.

B. "I will lower the head of your bed so you can lie flat": This statement may be relevant for certain procedures but is not specific to applying electrode gel pads for a 12-lead electrocardiogram.

C. "Relax and try not to move or speak once I have attached the gel pads": This instruction is essential for obtaining a clear and accurate electrocardiogram recording. Movement or talking during the procedure can interfere with the quality of the tracing.

D. "Try to hold your breath until this procedure is complete": This instruction is unnecessary and could cause discomfort or anxiety for the client. There is no need for the client to hold their breath during a standard electrocardiogram procedure.

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A nurse is caring for a client diagnosed with congestive heart failure and is taking digoxin daily. The client refused breakfast and is complaining of nausea and weakness. Which of the following actions should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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