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. Keep the client's personal items within reach.Keeping the client's personal items within reach can provide a sense of familiarity and comfort, which may reduce anxiety or disorientation, thereby decreasing the tendency to wander.
Incorrect options:
B. "Tell the family that someone should plan to stay with the client.": While family involvement is important, this suggestion may not always be feasible. Additionally, it’s the nurse’s role to ensure the safety of the client within the facility.
C. "Place the client in a quiet room at the end of the hallway.": Isolating the client may increase confusion and feelings of disorientation.
D. "Provide bright lighting in the client's room at night.": Bright lights at night can disrupt sleep and may cause further disorientation. Dim or soft lighting or use of night lights in the room is generally more appropriate to promote restful sleep.
Correct Answer is B
Explanation
A. Improved speech patterns:
While selegiline may contribute to overall improvement in motor function and quality of life for individuals with Parkinson's disease, it is not specifically known for targeting speech patterns.
B. Decreased tremors:
This is the correct therapeutic outcome. Selegiline is a monoamine oxidase type B (MAO-B) inhibitor that helps increase dopamine levels in the brain. Reduction of tremors is a common therapeutic effect in Parkinson's disease.
C. Increased bladder function:
Selegiline primarily affects motor symptoms in Parkinson's disease and is not directly associated with changes in bladder function.
D. Diminished drooling:
While drooling can be a symptom of Parkinson's disease, selegiline's primary focus is on motor symptoms, and its impact on drooling may be variable. Other interventions may be considered for managing drooling in Parkinson's disease.
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