A nurse is caring for a client who has 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?
Request a dietitian consult.
Suggest that the client rests before eating the meal.
Request an order for an antiemetic.
Check the client's vital signs.
The Correct Answer is D
The nurse should check the client's vital signs first because nausea and weakness are signs of digoxin toxicity, which can also cause bradycardia, hypotension, and arrhythmias. The nurse should also assess the client's serum digoxin level, potassium level, and electrocardiogram.
Request a dietitian consult is wrong because it is not the priority action and it does not address the possible cause of the client's symptoms. A dietitian consult may be helpful to provide nutritional education and guidance, but only after ruling out or treating digoxin toxicity.
Suggest that the client rests before eating the meal is wrong because it is not the priority action and it may delay the diagnosis and treatment of digoxin toxicity. The nurse should not assume that the client's symptoms are due to fatigue or lack of appetite, but rather investigate for any underlying problems.
Request an order for an antiemetic is wrong because it is not the priority action and it may mask the symptoms of digoxin toxicity. The nurse should not administer any medications that could interact with digoxin or worsen its effects, but rather notify the provider and follow the protocol for digoxin toxicity management.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A: Vertigo is a common finding in clients with essential hypertension due to changes in blood flow and possible impacts on the inner ear, which can affect balance.
B: Blurred vision, while it can be associated with hypertension, is not as directly related to essential hypertension as vertigo is. It is more commonly a sign of complications from prolonged uncontrolled hypertension.
C: Dyspnea or difficulty breathing is not typically a direct symptom of essential hypertension, though it can be a symptom of complications such as heart failure, which can be a result of long-standing, uncontrolled hypertension.
D: Uremia, which is an elevated level of waste products in the blood, is not a symptom of essential hypertension but rather a sign of kidney failure, which can be a secondary complication of chronic hypertension. Essential hypertension itself does not directly cause uremia.
Correct Answer is D
Explanation
The nurse should check the client's vital signs first because nausea and weakness are signs of digoxin toxicity, which can also cause bradycardia, hypotension, and arrhythmias. The nurse should also assess the client's serum digoxin level, potassium level, and electrocardiogram.
Request a dietitian consult is wrong because it is not the priority action and it does not address the possible cause of the client's symptoms. A dietitian consult may be helpful to provide nutritional education and guidance, but only after ruling out or treating digoxin toxicity.
Suggest that the client rests before eating the meal is wrong because it is not the priority action and it may delay the diagnosis and treatment of digoxin toxicity. The nurse should not assume that the client's symptoms are due to fatigue or lack of appetite, but rather investigate for any underlying problems.
Request an order for an antiemetic is wrong because it is not the priority action and it may mask the symptoms of digoxin toxicity. The nurse should not administer any medications that could interact with digoxin or worsen its effects, but rather notify the provider and follow the protocol for digoxin toxicity management.
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