A nurse is preparing to administer a dose of digoxin to a client who is experiencing heart failure. Which of the following actions should the nurse take prior to administering this medication?
Auscultate the client's lung sounds.
Check the client's weight
Check the client's apical pulse
Obtain the clients oxygen saturation
The Correct Answer is C
A. Auscultate the client's lung sounds: While assessing lung sounds is an important part of the overall assessment for a client with heart failure (to check for pulmonary edema/crackles), it is not a specific requirement for the administration of digoxin. It helps evaluate the effectiveness of the treatment over time but does not determine if the current dose is safe to give.
B. Check the client's weight: Daily weights are essential for monitoring fluid volume status in heart failure patients. However, like lung sounds, this is an assessment of the disease progression rather than a safety check for the medication's immediate effect on the heart's electrical system.
C. Check the client's apical pulse: Digoxin can cause bradycardia and other arrhythmias. The nurse must assess the apical pulse for a full minute before administration and withhold the medication if the rate is below the provider’s prescribed parameters (commonly <60 bpm in adults).
D. Obtain the client's oxygen saturation: Oxygen saturation provides information about respiratory status but does not directly influence the decision to administer digoxin.
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Related Questions
Correct Answer is C
Explanation
A. Admission vital signs: While admission vital signs are part of the client’s history, they are not usually relevant for change-of-shift reporting unless there has been a trend or abnormal finding that impacts current care. Reporting outdated vitals does not inform immediate clinical decisions.
B. Steps required for dressing change: Detailed procedural steps are not typically included in shift reports. The report should focus on current status, recent changes, and ongoing care needs rather than teaching or step-by-step instructions.
C. Time of last pain medication: Reporting the time of the last analgesic dose is important for continuity of care. It helps the incoming nurse assess pain control, schedule subsequent doses, and anticipate the client’s comfort needs.
D. Preferred bath time: While client preferences are helpful for planning care, they are not critical information for clinical decision-making during a shift report. This detail can be communicated during routine care rather than formal handoff.
Correct Answer is A
Explanation
A. The weights apply a pulling force continuously: Proper functioning of Buck’s traction requires that the weights hang freely and apply a constant, uninterrupted pulling force. Continuous traction maintains alignment, reduces muscle spasm, and prevents further injury.
B. The boot allows active leg movement: Active movement of the affected leg is restricted in Buck’s traction to maintain proper alignment and traction. Excessive movement can interfere with the traction force and compromise treatment effectiveness.
C. The weights are just touching the floor: Weights should hang freely without touching the floor. Contact with the floor reduces the effective traction force and prevents the system from functioning as intended.
D. The footplate rests against the foot of the bed: The footplate should not rest against the bed, as this can alter alignment and reduce traction effectiveness. Proper positioning requires clear space to allow the traction system to work correctly.
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