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 ["A","B","D","E"]

Explanation

A. Elevating the head of the bed 30 to 45 degrees helps prevent aspiration, which is a risk factor for ventilator-associated pneumonia.
B. Performing hand hygiene before touching the ventilator tubing is crucial to prevent the introduction of pathogens into the ventilator system.
C. Refraining from suctioning the client is incorrect; suctioning should be performed as needed to keep the airway clear.
D. Providing mouth care every 2-4 hours can reduce the risk of pathogens entering the lower respiratory tract.
E. Performing hand hygiene before touching the client reduces the risk of transmitting infectious agents to the client.

A. Lime B. Hydrofluric acid C. Bleach D. Fabric softener E. Gasoline

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

Explanation

A. Lime: Lime can cause chemical burns, especially when in contact with moisture (e.g., skin or eyes), but it is less common than some other agents listed.

B. Hydrofluric acid: Hydrofluoric acid is highly corrosive and can cause severe burns upon contact with the skin or mucous membranes.

C. Bleach: Bleach, particularly sodium hypochlorite, is a common household chemical that can cause chemical burns, especially in concentrated forms.

D. Fabric softener: While fabric softeners contain chemicals, they are not typically known to cause significant chemical burns unless ingested or used improperly.

E. Gasoline: Gasoline is a flammable liquid that can cause chemical burns upon skin contact.

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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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Explanation

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