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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Use humor to decrease tension: Humor may not translate well across cultures and languages, and it can lead to miscommunication or offend the client unintentionally. It is better to maintain a respectful, clear, and professional communication style when using an interpreter.
B. Speak in short sentences: Using short, clear sentences helps the interpreter accurately convey the nurse’s message to the client. It allows for better understanding and avoids overwhelming the interpreter with complex information that could get misinterpreted.
C. Speak in third person: Speaking in third person can cause confusion and distance the nurse from the client. It is best to speak directly to the client using first and second person ("I" and "you") so the interaction feels more personal and respectful.
D. Talk directly to the interpreter: The nurse should always speak directly to the client, maintaining eye contact and body language with the client. The interpreter is there to facilitate communication, not to replace the direct interaction between the nurse and the client.
Correct Answer is B
Explanation
A. "I limit my time spent out in the sunlight.": While moderate sun exposure can be beneficial for psoriasis, excessive sun exposure can worsen the condition or increase the risk of skin cancer. Limiting sunlight is generally a safe practice unless the client is avoiding it entirely, which is not indicated here.
B. "I try not to look at the scales on my body.": This statement suggests significant emotional distress or poor coping related to body image. Psoriasis can have profound psychological effects, including depression and anxiety, which must be reported to the provider to address the client’s mental health needs alongside physical treatment.
C. "I remove old medication on my skin before applying a new dose.": Proper application of topical medications includes cleaning old residue to promote better absorption of the new dose. This practice is appropriate and demonstrates an understanding of correct medication use.
D. "I do not use fabric softener when I wash my clothing.": Avoiding fabric softeners is a helpful strategy for clients with psoriasis because softeners can leave residues that irritate sensitive skin. This statement reflects good self-care behavior rather than a concern needing provider intervention.
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