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 B
Explanation
Right-sided heart failure is a condition in which the right ventricle fails to pump blood effectively to the lungs, causing a backup of blood in the systemic circulation. This leads to increased pressure in the right atrium and the vena cava, which can be measured by the central venous pressure (CVP). A normal CVP is 2 to 6 mm Hg, but in right-sided heart failure, it can rise above 10 mm Hg. Symptoms of right-sided heart failure include peripheral edema, jugular venous distension, hepatomegaly, ascites, and weight gain.
a. Increased pulmonary artery wedge pressure (PAWP). This statement is incorrect because it describes a finding of left-sided heart failure, not right-sided heart failure. Left-sided heart failure is a condition in which the left ventricle fails to pump blood effectively to the systemic circulation, causing a backup of blood in the pulmonary circulation. This leads to increased pressure in the left atrium and the pulmonary capillaries, which can be measured by the pulmonary artery wedge pressure (PAWP). A normal PAWP is 6 to 12 mm Hg, but in left-sided heart failure, it can rise above 18 mm Hg. Symptoms of left-sided heart failure include dyspnea, orthopnea, paroxysmal nocturnal dyspnea, crackles in the lungs, and pink frothy sputum.
c. Decreased brain natriuretic peptide (BNP). This statement is incorrect because it describes a finding of normal or reduced cardiac function, not heart failure. Brain natriuretic peptide (BNP) is a hormone secreted by the cardiac cells in response to increased stretch and pressure in the ventricles. It acts as a diuretic and a vasodilator, lowering blood volume and blood pressure. BNP is used as a biomarker for diagnosing and monitoring heart failure, as it reflects the degree of ventricular dysfunction. A normal BNP level is less than 100 pg/mL, but in heart failure, it can rise above 400 pg/mL.
d. Decreased specific gravity. This statement is incorrect because it describes a finding of dilute urine, not concentrated urine. Specific gravity is a measure of the concentration of solutes in urine, reflecting the ability of the kidneys to regulate fluid balance. A normal specific gravity is 1.005 to 1.030, but it can vary depending on fluid intake and output, hydration status, and renal function. In right-sided heart failure, fluid retention and reduced renal perfusion can cause oliguria and increased specific gravity of urine.
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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