A nurse is preparing to administer a new prescription for digoxin 0.125 mg orally once daily to a client who has heart failure. Which of the following actions should the nurse take before giving the medication?
Check the client's apical pulse for one full minute.
Check the client's serum potassium level.
Check the client's blood pressure in both arms.
Check the client's serum digoxin level.
The Correct Answer is A
A) Correct. The nurse should check the client's apical pulse for one full minute before giving digoxin as this drug can cause bradycardia and heart block. The nurse should withhold the medication and notify the provider if the pulse is less than 60 beats/min or irregular.
B) Incorrect. The nurse should check the client's serum potassium level periodically while taking digoxin as this drug can cause hypokalemia or hyperkalemia, which can affect its therapeutic effect and toxicity. However, this is not a priority action before giving each dose of digoxin.
C) Incorrect. The nurse should check the client's blood pressure in both arms periodically while taking digoxin as this drug can cause hypotension or hypertension, which can affect its efficacy and safety. However, this is not a priority action before giving each dose of digoxin.
D) Incorrect. The nurse should check the client's serum digoxin level periodically while taking digoxin as this drug has a narrow therapeutic range and can cause toxicity if the level is above 2 ng/mL. However, this is not a priority action before giving each dose of digoxin.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
B) Correct. The nurse should obtain a blood sample from the client for a complete blood count as these symptoms can indicate agranulocytosis, a potentially fatal adverse effect of clozapine that causes a severe decrease in white blood cells and increases the risk of infection.
A) Incorrect. The nurse should not administer acetaminophen to the client as this drug can mask the signs of infection and delay diagnosis and treatment of agranulocytosis.
C) Incorrect. The nurse should encourage the client to drink plenty of fluids and rest, but this action alone would not address the potential serious adverse effect of agranulocytosis associated with clozapine. Obtaining a blood sample for a complete blood count is necessary to assess the client's white blood cell count and determine if agranulocytosis is present.
D) Incorrect. Discontinuing clozapine and notifying the provider is important, but it should be done after obtaining a blood sample for a complete blood count to confirm the presence of agranulocytosis. This allows for appropriate medical management and alternative treatment options to be initiated.
Correct Answer is A
Explanation
A) Correct. The nurse should check the client's apical pulse for one full minute before giving digoxin as this drug can cause bradycardia and heart block. The nurse should withhold the medication and notify the provider if the pulse is less than 60 beats/min or irregular.
B) Incorrect. The nurse should check the client's serum potassium level periodically while taking digoxin as this drug can cause hypokalemia or hyperkalemia, which can affect its therapeutic effect and toxicity. However, this is not a priority action before giving each dose of digoxin.
C) Incorrect. The nurse should check the client's blood pressure in both arms periodically while taking digoxin as this drug can cause hypotension or hypertension, which can affect its efficacy and safety. However, this is not a priority action before giving each dose of digoxin.
D) Incorrect. The nurse should check the client's serum digoxin level periodically while taking digoxin as this drug has a narrow therapeutic range and can cause toxicity if the level is above 2 ng/mL. However, this is not a priority action before giving each dose of digoxin.
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