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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

Planning to slow down if tired the day after exercising is a statement that indicates the client understands the importance of pacing activities and avoiding overexertion, which can worsen heart failure symptoms.

a. "I should use naproxen to manage discomfort." is not correct, as naproxen is a nonsteroidal anti-inﬂammatory drug (NSAID) that can cause ﬂuid retention, increase blood pressure, and worsen heart failure. The client should avoid NSAIDs and use other analgesics, such as acetaminophen, unless contraindicated.

c. "I will read food labels and limit my sodium to 4 grams per day." is not appropriate, as 4 grams of sodium per day is too high for a client who has congestive heart failure. The client should limit sodium intake to 2 grams or less per day, as sodium can cause ﬂuid retention and increase the workload of the heart.

d. "I will take my diuretic before sleep and drink ﬂuids during the day." is not advisable, as taking a diuretic before sleep can cause nocturia and disrupt the sleep cycle, which can aﬀect the quality of life and cardiac function. The

A. "A headache is an indication of an allergy to the medication." B. "A headache indicates tolerance to the medication." C. "A headache is likely due to the anxiety about the chest pain." D. "A headache is an expected adverse eﬀect of the medication."

Correct Answer is D

Explanation

A headache is a common and expected adverse eﬀect of nitroglycerin, due to its vasodilating action. The client can take an over-the-counter analgesic to relieve the headache, unless contraindicated.

"A headache is an indication of an allergy to the medication." is not correct, as a headache is not a sign of an allergic reaction to nitroglycerin. An allergic reaction would manifest as rash, itching, swelling, or difficulty breathing.

"A headache indicates tolerance to the medication." is not accurate, as a headache does not indicate tolerance to nitroglycerin. Tolerance would manifest as reduced or absent relief from anginal pain.

"A headache is likely due to the anxiety about the chest pain." is not plausible, as a headache is not likely due to the anxiety about the chest pain. Anxiety would manifest as nervousness, restlessness, palpitations, or sweating.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing discharge instructions for a client who has congestive heart failure. Which of the following client statements indicates to the nurse that the teaching was eﬀective?

Correct Answer is B

Explanation

A nurse in the emergency department is caring for a client who took 3 nitroglycerin tablets sublingually for chest pain. The client reports relief from the chest pain but now he is experiencing a headache. Which of the following statements should the nurse make?

Correct Answer is D

Explanation

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