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 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 client's oxygen saturation
The Correct Answer is C
A. Auscultate the client's lung sounds: While lung sounds are important to assess in clients with heart failure, auscultating lung sounds is not directly required before administering digoxin. The immediate concern with digoxin is its effect on heart rate and rhythm.
B. Check the client's weight: Monitoring weight is important in heart failure management to assess fluid retention, but weight measurement is not necessary immediately prior to administering a dose of digoxin.
C. Check the client's apical pulse: Before giving digoxin, it is critical to assess the client's apical pulse for one full minute. If the pulse is below a specified rate (60 beats/min for adults), the dose may need to be withheld and the provider notified due to the risk of digoxin-induced bradycardia.
D. Obtain the client's oxygen saturation: Oxygen saturation is important in evaluating respiratory function, but it is not a priority action before administering digoxin. The primary safety check is heart rate assessment.
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Related Questions
Correct Answer is D
Explanation
A. Difficulty swallowing: Difficulty swallowing, or dysphagia, is not typically a direct indicator of unrelieved pain. It could suggest neurological or throat-related issues rather than being a primary symptom associated with inadequate pain control.
B. Constipation: Constipation is a common postoperative complication, often related to anesthesia, immobility, or opioid use. While it is important to address, it does not directly reflect the client's current pain level or effectiveness of pain management.
C. Urinary retention: Urinary retention can occur due to anesthesia effects, pelvic surgery, or opioid administration. Although it is a significant postoperative concern, it is not a reliable or direct indicator of unrelieved pain.
D. Restlessness: Restlessness is a common sign of unrelieved pain, particularly in postoperative clients. When clients are uncomfortable or in significant pain, they may appear restless, anxious, or unable to remain still, signaling the need for further pain assessment and intervention.
Correct Answer is A
Explanation
A. Reviewing the results of the client's chlamydia screening with their parents, without the client's consent: Sexual health information, including STI screenings, is protected by confidentiality laws even for minors in many regions. Disclosing such sensitive information without the client's consent breaches confidentiality and can undermine trust between the adolescent and healthcare providers.
B. Reviewing the results of the client's celiac screening with their parents, without the client's consent: Celiac screening relates to general medical conditions and nutritional health, which are typically shared with parents of minors unless otherwise restricted. This does not generally breach confidentiality because it is not considered sensitive under adolescent health privacy laws.
C. Reviewing the results of the client's complete blood count (CBC) with their parents, without the client's consent: A CBC is a routine diagnostic test that checks general health indicators such as anemia or infection. Discussing these results with parents, especially for minors, is standard practice and does not usually violate confidentiality.
D. Reviewing the results of the client's urinalysis with their parents, without the client's consent: Urinalysis results typically assess general health or identify infections, which are standard to share with parents in the care of minors. This action would not be considered as a breach of confidentiality unless it revealed sensitive information like substance use without consent.
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