A nurse is caring for a client who has heart failure and has been taking digoxin 0.25 mg daily. The client refuses breakfast and reports nausea. Which of the following actions should the nurse take first?
Request a dietary consult.
Check the client's vital signs.
Request an order for an antiemetic.
Suggest that the client rests before eating the meal.
The Correct Answer is B
A. Request a dietary consult:
While dietary concerns may be addressed, checking vital signs is the priority when a client reports nausea, especially in the context of medication administration.
B. Check the client's vital signs:
This is the correct action. Nausea can be a symptom of digoxin toxicity. Checking vital signs, especially assessing for changes in heart rate, is crucial in determining whether the client is experiencing adverse effects of digoxin.
C. Request an order for an antiemetic:
Administering an antiemetic may be considered later, but the first priority is to assess the client's vital signs and determine if the nausea is related to digoxin toxicity.
D. Suggest that the client rests before eating the meal:
Resting before eating may be helpful for nausea, but the priority is to assess the client's vital signs and determine the cause of the nausea, especially in the context of digoxin use.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. "It is a good idea to use the handrails in the bathroom":
This statement reflects an understanding of the importance of using handrails in the bathroom for stability and support, especially when getting in and out of the bathtub or shower. Using handrails can prevent slips and falls in this high-risk area.
B. "I should use chairs without armrests":
Using chairs without armrests may not necessarily contribute to fall prevention. Chairs with armrests can provide additional support and stability when sitting down or getting up.
C. "I should place a throw rug over electrical cords":
Placing a throw rug over electrical cords creates a tripping hazard. It is not a safe practice and contradicts fall prevention measures. Throw rugs should be secured and not placed over cords.
D. "I should get a longer cord for my telephone":
Getting a longer cord for the telephone may not be directly related to fall prevention. It is important to focus on measures that enhance safety and reduce fall risks, such as proper lighting, clear pathways, and the use of assistive devices.
Correct Answer is A
Explanation
A. Discontinuing the existing IV infusion is the priority when signs of infection or inflammation are present at the site. This action helps prevent the spread of infection and allows for a thorough assessment of the site.
B. Inserting an IV catheter in the opposite extremity is not the first step. Before considering a new IV site, it's crucial to address the issue with the current site. Starting a new IV line before addressing the potential infection could lead to further complications.
C. Applying warm, moist compresses to the site is not the first action. While warm compresses can be used to promote blood flow and comfort, the priority is to discontinue the current infusion and assess for infection or inflammation.
D. Elevating the extremity is not the first action in response to signs of infection or inflammation at an IV site. The priority is to discontinue the infusion and assess the site for potential complications.
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