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

Answer and Explanation

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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Correct Answer is A

Explanation

A. "I really wish I had a girl instead.": Expressing disappointment in the baby's gender may indicate difficulty bonding with the infant or potential postpartum emotional concerns. This statement warrants further evaluation to assess for postpartum depression or attachment issues.

B. "I am so relieved the baby looks like my mother.": Feeling relieved that the baby resembles a family member is a normal emotional reaction and does not typically require further psychological evaluation unless associated with more concerning behaviors.

C. "My labor was so long I'm glad it's over.": Expressing relief after a long labor is a normal reaction and does not indicate emotional distress or dysfunction that would need further mental health evaluation.

D. "My appetite has really increased.": An increased appetite two weeks postpartum is a normal physiological response as the body recovers from childbirth, particularly if the client is breastfeeding. It does not suggest a need for further emotional or physical evaluation.

A. "I limit my time spent out in the sunlight B. "I try not to look at the scales on my body." C. "I remove old medication on my skin before applying a new dose." D. "I do not use fabric softener when I wash my clothing"

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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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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