A nurse is monitoring a client who received a local injection of lidocaine. Which of the following responses should the nurse expect?

A. Remove the medication from the medication dispensing cabinet: While removing the medication from the dispensing cabinet is a necessary step in the medication administration process, it is not the first action the nurse should take. Ensuring proper client identification is the priority to prevent medication errors.

B. Identify the client using two identifiers: This is the first action the nurse should take before administering any medication, especially controlled substances. Using at least two unique identifiers, such as the client's name and date of birth or medical record number, helps ensure that the right medication is administered to the right patient.

C. Document the administration of the medication: Documentation is an essential step in the medication administration process, but it should occur after the medication has been administered. Proper documentation helps maintain an accurate record of the medication administration and the client's response to the medication.

D. Compare the amount of medication available to the inventory record: While reconciling the amount of medication available to the inventory record is important for maintaining accurate medication stock levels, it is not the first action the nurse should take before administering a controlled substance. Client identification takes precedence to prevent medication errors and ensure patient safety.

A. “Taking an HMG CoA reductase inhibitor”: HMG CoA reductase inhibitors, also known as statins, are used to lower cholesterol levels. While they can interact with many medications, they do not specifically predispose a client to developing digoxin toxicity.

B. “Having a prolapsed mitral valve”: A prolapsed mitral valve can lead to mitral valve regurgitation and potentially heart failure, but it does not specifically predispose a client to developing digoxin toxicity.

C. “Taking a high-ceiling diuretic”: This is the correct answer. High-ceiling diuretics, also known as loop diuretics, can cause electrolyte imbalances, particularly low potassium levels (hypokalemia). Digoxin toxicity is more likely to occur when potassium levels are low, as digoxin and potassium compete for the same binding sites in the body. Therefore, taking a high-ceiling diuretic can predispose a client to developing digoxin toxicity.

D. “Having a 10-year history of COPD”: While chronic obstructive pulmonary disease (COPD) can exacerbate heart failure symptoms, it does not specifically predispose a client to developing digoxin toxicity.