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
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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Related Questions
Correct Answer is B
Explanation
A. Obtain pulse oximetry every two hours: While monitoring oxygen saturation is important in assessing respiratory status, it is not a direct intervention for preventing atelectasis. It is more of an assessment tool to evaluate the effectiveness of interventions aimed at preventing atelectasis.
B. Teach the client how to use the incentive spirometer: Incentive spirometry is a valuable tool for preventing atelectasis postoperatively by promoting deep breathing and lung expansion. Teaching the client how to use the incentive spirometer and encouraging its frequent use can help maintain lung volume and prevent collapse of alveoli.
C. Instruct the client to practice abdominal breathing: While abdominal breathing can be beneficial for promoting relaxation and reducing anxiety, it is not as effective as incentive spirometry in preventing atelectasis postoperatively.
D. Encourage oral fluid intake of 2000 mL/24 hours: Adequate hydration is important for overall health and respiratory function, but it is not specifically targeted at preventing atelectasis. While hydration can help maintain airway secretions thin, it is not the primary intervention for preventing atelectasis after a lobectomy.
Correct Answer is D
Explanation
A. Constipation: Constipation is not a common adverse effect of Atenolol, which is a beta- blocker.
B. Cough: Cough is more commonly associated with ACE inhibitors rather than beta-blockers like Atenolol.
C. Tremor: Tremor is not typically an adverse effect of Atenolol; beta-blockers can actually be used to treat essential tremors.
D. Bradycardia: Atenolol, as a beta-blocker, can slow the heart rate, leading to bradycardia, which is a well-documented adverse effect.
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