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 C
Explanation
A. Assist a client to eat who has difficulty seeing the foods on the tray.
Assisting a client with eating is a routine task that an AP can perform, especially when the client has difficulty with vision.
B. Provide postmortem care for a client who has died.
Postmortem care involves preparing the body of a deceased client. While it requires sensitivity, it is a task that can be appropriately delegated to assistive personnel.
C. Observe a confused surgical client who has multiple tubes.
Observing a confused client with multiple tubes requires a level of assessment and decision-making that goes beyond the scope of practice for an assistive personnel (AP). This task involves monitoring the client's condition, recognizing changes, and responding appropriately, which should be performed by a licensed nurse.
D. Deliver a client's urine specimen to the laboratory.
Transporting a urine specimen to the laboratory is a task that an assistive personnel can perform, as it does not involve interpretation or assessment of the specimen.
Correct Answer is D
Explanation
A. Move any clients in the immediate vicinity.
This is a reasonable next step, ensuring the safety of clients in close proximity to the potentially hazardous situation.
B. Close the fire doors on the unit.
Closing fire doors is important for containing the spread of smoke and fire, but it may be a secondary action after alerting others to the emergency using the fire alarm.
C. Use a fire extinguisher on the outlet.
While fire extinguishers can be useful in certain situations, using one on an electrical fire can be dangerous. It's generally recommended to leave firefighting to trained personnel and focus on evacuation and alerting others.
D. Activate the fire alarm.
Activating the fire alarm is the priority because it alerts everyone in the facility to the potential danger, ensuring a prompt and coordinated response. It initiates the facility's fire response plan and helps in the evacuation of patients if necessary.
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