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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Protamine sulfate: Protamine sulfate is used to reverse the effects of heparin, not warfarin. Administering it in warfarin toxicity would not effectively counteract the anticoagulant effect and could delay appropriate treatment.
B. Vitamin K: Vitamin K is the antidote for warfarin toxicity. It promotes synthesis of clotting factors II, VII, IX, and X, which are inhibited by warfarin, helping to restore normal coagulation and reduce the risk of bleeding.
C. Calcium gluconate: Calcium gluconate is primarily used to treat hypocalcemia or cardiac effects of hyperkalemia. It does not reverse warfarin-induced anticoagulation and would not address the underlying risk of bleeding.
D. Acetylcysteine: Acetylcysteine is an antidote for acetaminophen toxicity and works by replenishing glutathione. It has no effect on warfarin metabolism or clotting factor synthesis, making it inappropriate for this scenario.
Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"C"}
Explanation
Rationale for correct choices:
• N95 respirator: Mycobacterium tuberculosis is transmitted via airborne particles that remain suspended in the air. An N95 respirator is required to filter airborne droplet nuclei and protect the nurse from inhalation exposure. Standard surgical masks do not provide adequate airborne protection in confirmed TB cases.
• Gloves: As part of Standard Precautions, gloves should always be worn when there is a risk of contact with body fluids, such as sputum or contaminated surfaces in the client's room.
Rationale for incorrect choices:
• Surgical mask: A surgical mask protects against large respiratory droplets but does not filter airborne particles. TB requires airborne precautions, which exceed the level of protection provided by a standard mask. Surgical masks are more appropriate for droplet-based infections.
• Face shield: A face shield protects mucous membranes from splashes or sprays but does not filter inhaled air. TB does not spread via splashes, making this equipment unnecessary for routine airborne precautions. Respiratory protection remains the priority.
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