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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A,B"},"C":{"answers":"A,B"},"D":{"answers":"A"}}
Explanation
• Hemoglobin: Hemoglobin is within normal limits at 12.5 g/dL. HELLP syndrome involves hemolysis, which could lower hemoglobin, but in this case, there is no evidence of anemia yet. Preeclampsia may cause hemoconcentration, but the client’s hemoglobin is not abnormal.
• Platelet count: The client’s platelet count is 98,000/mm³, below the normal range. Thrombocytopenia is a hallmark of HELLP syndrome and can also occur in severe preeclampsia. Low platelets increase bleeding risk and indicate systemic endothelial dysfunction. Monitoring platelet trends is critical for anticipating complications and guiding treatment.
• Liver enzymes: AST and ALT are elevated (38 and 40 units/L), reflecting hepatocellular injury. Elevated liver enzymes are a defining component of HELLP syndrome (hemolysis, elevated liver enzymes, low platelets) and are commonly seen in preeclampsia due to hepatic involvement.
• Fibrinogen: Fibrinogen is elevated at 500 mg/dL. HELLP syndrome involves a hypercoagulable state with microangiopathic hemolysis and liver involvement, often causing changes in fibrinogen levels. Elevated fibrinogen supports the presence of HELLP syndrome.
Correct Answer is A
Explanation
A. Wear cotton underwear: Cotton underwear allows better air circulation and reduces moisture accumulation, which helps prevent bacterial growth in the genital area. Proper underwear choice is a simple preventive measure that supports urinary tract health.
B. Drink orange juice daily for 3 to 4 weeks: While vitamin C may help acidify urine slightly, there is no evidence supporting long-term consumption specifically for UTI prevention. Excessive intake can also irritate the bladder or cause gastrointestinal upset.
C. Take the prescribed antibiotic until manifestations are gone: Antibiotics should be taken for the full prescribed course, not just until symptoms resolve. Stopping early can lead to incomplete eradication of bacteria and increase the risk of resistance.
D. Restrict fluid intake to 1 L per day: Restricting fluids can worsen UTIs by reducing urine output, which limits bacterial flushing from the urinary tract. Adequate hydration is recommended to help prevent and manage UTIs.
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