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
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Complete Heart Block: Complete heart block (third-degree AV block) occurs when there is no communication between the atria and ventricles. The atria and ventricles beat independently, resulting in a very slow ventricular rate. This rhythm is characterized by regular P waves that have no relation to the QRS complexes.
B. Sinus Tachycardia: Sinus tachycardia is a rhythm originating from the sinoatrial node with a heart rate typically between 100-150 beats per minute. The rhythm is regular, and the P waves precede each QRS complex consistently.
C. Ventricular Tachycardia: Ventricular tachycardia is a fast heart rhythm that originates from the ventricles. It is characterized by wide and abnormal QRS complexes with a rate usually between 150-250 beats per minute. There may be no visible P waves, and if present, they are not associated with the QRS complexes.
D. Idioventricular Rhythm: Idioventricular rhythm is a slow rhythm originating from the ventricles with a heart rate usually between 20-40 beats per minute. It has wide and abnormal QRS complexes and no visible P waves.
Correct Answer is B
Explanation
A. Morphine sulfate 2 mg IV bolus every 2 hr PRN pain: This prescription is appropriate for managing pain associated with acute heart failure and MI.
B. Bumetanide 1 mg IV bolus every 12 hr: Bumetanide is a loop diuretic commonly used in heart failure to reduce fluid overload. However, the frequency of administration (every 12 hours) may not be sufficient for managing acute heart failure, where more frequent dosing may be necessary initially.
C. Laboratory testing of serum potassium upon admission: This is a routine and appropriate order to monitor electrolyte balance, especially with the use of diuretics.
D. 0.9% normal saline IV at 75 mL/hr: This is a maintenance IV fluid rate that may be appropriate depending on the client's fluid status. However, it does not directly address acute heart failure.
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