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
Turn the client's head to the side.
The nurse should turn the client's head to the side first to prevent aspiration of oral secretions and maintain a patent airway. This is the priority action according to the airway, breathing, and circulation (ABC) principle.
Check the client's motor strength is wrong because it is not the priority action and it is not feasible during a seizure. The nurse should check the client's motor strength after the seizure to assess for any neurological deficits or postictal weakness.
Document the time the seizure began is wrong because it is not the priority action and it can be done later. The nurse should document the time, duration, type, and characteristics of the seizure, but only after ensuring the client's safety and well-being.
Loosen the clothing around the client's waist is wrong because it is not the priority action and it may not be necessary. The nurse should loosen any tight clothing that could impair breathing or circulation, but only after securing the airway and protecting the head from injury.
Turn the client's head to the side.
The nurse should turn the client's head to the side first to prevent aspiration of oral secretions and maintain a patent airway. This is the priority action according to the airway, breathing, and circulation (ABC) principle.
Check the client's motor strength is wrong because it is not the priority action and it is not feasible during a seizure. The nurse should check the client's motor strength after the seizure to assess for any neurological deficits or postictal weakness.
Document the time the seizure began is wrong because it is not the priority action and it can be done later. The nurse should document the time, duration, type, and characteristics of the seizure, but only after ensuring the client's safety and well-being.
Loosen the clothing around the client's waist is wrong because it is not the priority action and it may not be necessary. The nurse should loosen any tight clothing that could impair breathing or circulation, but only after securing the airway and protecting the head from injury.
Correct Answer is ["75"]
Explanation
To calculate the infusion rate, divide the volume of fluid by the time in hours. In this case, 1800 mL / 24 hr = 75 mL/hr.
Round the answer to the nearest whole number and use a leading zero if it applies.
Do not use a trailing zero because it could be misread as a decimal point. Therefore, the nurse should set the IV pump to deliver 75 mL/hr.
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