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: Location A is near the infant’s foot, specifically around the ankle. This area is where the posterior tibial or dorsalis pedis pulse would be palpated, not the femoral pulse. These pulses are important for assessing peripheral circulation but are not the primary site for evaluating coarctation of the aorta, which requires checking central pulses like the femoral.
B: Location B is at the upper inner thigh, near the groin, where the femoral artery passes close to the skin surface. This is the correct site for palpating the femoral pulse in an infant. In conditions like coarctation of the aorta, comparing the strength of the brachial and femoral pulses is crucial to detect differences in blood flow between the upper and lower body.
C: Location C is on the upper arm, near the shoulder area, which corresponds to the location for checking the brachial pulse. The brachial pulse is commonly used in infants to assess heart rate, especially during resuscitation efforts. However, it is not the site for assessing femoral pulse strength, which is needed when evaluating for coarctation of the aorta.
Correct Answer is A
Explanation
A. BMI 32: A BMI of 30 or higher indicates obesity, which is a major risk factor for developing type 2 diabetes mellitus. Excess body fat, especially abdominal fat, contributes to insulin resistance, increasing the likelihood of diabetes.
B. Alcohol use: While excessive alcohol intake can affect overall health, moderate alcohol consumption is not a primary direct risk factor for type 2 diabetes. Other factors like obesity and sedentary lifestyle have a stronger association.
C. Age 35 years: Advancing age increases diabetes risk, but significant age-related risk typically rises after age 45. At 35 years old, age alone is not considered a major risk factor without additional contributing conditions.
D. Medical history of asthma: Asthma is a chronic respiratory condition but is not recognized as a risk factor for type 2 diabetes mellitus. The primary risk factors involve metabolic, genetic, and lifestyle components rather than respiratory history.
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