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.

Answer and Explanation

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.

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Correct Answer is ["A","B","E"]

Explanation

A. Client understands the surgical procedure:

The client should have a clear understanding of the proposed surgical procedure, its risks, benefits, alternatives, and potential complications.

B. Voluntary consent is given:

The client's consent should be given voluntarily, without coercion or pressure from healthcare providers or others.

C. Client's ability to read the consent form:

While it is helpful for clients to be able to read the consent form, the ability to read the form is not a requirement for valid consent. The information should be explained verbally if the client cannot read.

D. Client's ability to pay for the consented surgical procedure:

The client's ability to pay for the procedure is not a factor in obtaining informed consent. Financial considerations do not affect the validity of the consent.

E. Disclosure of the treatment is provided:

Healthcare providers must disclose information about the proposed treatment, including its nature, purpose, risks, benefits, and potential alternatives, allowing the client to make an informed decision.

A. Interpreting a client's vital signs B. Providing postmortem care on a client who has died C. Performing a central line dressing change for a client D. Educating a client on the use of a blood glucose monitor

Correct Answer is B

Explanation

A. Interpreting a client's vital signs requires clinical judgment and understanding of the significance of the vital sign values. This task is within the scope of licensed nursing practice and should not be delegated to an assistive personnel.

B. Providing postmortem care involves tasks such as cleaning and preparing the body with dignity and respect. While this task requires sensitivity, it does not involve making clinical judgments or performing procedures that are beyond the scope of an assistive personnel's role.

C. Performing a central line dressing change for a client is a skilled nursing procedure that involves aseptic technique and the potential for complications. This task is within the scope of licensed nursing practice and should not be delegated to an assistive personnel.

D. Educating a client on the use of a blood glucose monitor involves providing information and ensuring the client's understanding. This task requires communication skills and teaching abilities, which are within the scope of licensed nursing practice. It should not be delegated to an assistive personnel.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is obtaining informed consent from a client prior to surgery. Which of the following is necessary for informed consent to be valid? (Select all that apply.)

Correct Answer is ["A","B","E"]

Explanation

A nurse is assigning care to an assistive personnel (AP). Which of the following tasks should the nurse delegate to the AP?

Correct Answer is B

Explanation

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