A nurse is preparing to administer digoxin orally to a client. Identify the sequence of steps the nurse should take (Move the steps into the box on the right, placing them in the order of performance. Use all the steps)

Remove the medication from the dispensing system.

Compare the client’s wristband to the medication administration record.

Document administration of the medication.

Open the medication package.

Obtain the client’s apical heart rate.

Answer and Explanation

The Correct Answer is E, A, B, D, C

Before administering digoxin, the nurse should check the patient's apical heart rate. If the heart rate is below 60 beats per minute for an adult, or below the prescribed limit for a child, the nurse should hold the medication and notify the healthcare provider. This is the first step because the nurse needs to have the medication in hand before proceeding with the other steps. This step is crucial to ensure that the right medication is being given to the right patient. It's a part of the "five rights" of medication administration: right patient, right medication, right dose, right route, and right time. Once the nurse has confirmed the patient's identity and heart rate, the next step is to open the medication package. After administering the medication, the nurse should document it in the patient's medical record. This is important for maintaining an accurate record of the patient's medication history.

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Correct Answer is C

Explanation

During a seizure, the client may experience excessive oral secretions or may vomit, which can obstruct the airway and lead to aspiration. Having oral suction readily available allows the nurse to quickly and effectively clear the airway and maintain adequate oxygenation and ventilation during and after the seizure.
A While maintaining a comfortable room temperature is important for the client's overall comfort, it is not the most essential intervention during a seizure. The priority is to ensure immediate safety and airway protection.
B Positioning the client in a semi-Fowler's position may be beneficial for airway management and respiratory function, but it is not the most essential intervention during a seizure.
D While providing mouth care is important for oral hygiene, it is not the most essential intervention during a seizure. The priority during a seizure is to ensure airway patency and safety, particularly regarding the risk of aspiration.

A. Palpate the right flank for tenderness. B. Evaluate the urine for a strong odor. C. Test the urine for the presence of hematuria. D. Measure the temperature and pulse rate.

Correct Answer is D

Explanation

D. In a client presenting with urinary symptoms and lower back pain, measuring the temperature and pulse rate is essential for assessing for signs of systemic infection, such as fever (elevated temperature) and tachycardia (elevated pulse rate). These vital signs can help determine the urgency of the situation and guide further assessment and management.
A. Palpating the right flank for tenderness may be appropriate to assess for signs of kidney involvement, such as in pyelonephritis. However, this intervention is not the first priority. Assessing for systemic signs of infection, such as fever, is more urgent.
B. Evaluating the urine for a strong odor may provide additional information about the student's symptoms, but it is not the first intervention priority.

C. Testing the urine for the presence of hematuria (blood in the urine) is an important diagnostic step in evaluating urinary symptoms, but it is not the first intervention priority. Hematuria may be present in various conditions, including UTIs, kidney stones, or other urinary tract disorders.

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A nurse is preparing to administer digoxin orally to a client. Identify the sequence of steps the nurse should take (Move the steps into the box on the right, placing them in the order of performance. Use all the steps)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a client that is unconscious and having seizures. Which nursing intervention is most essential in this client's plan of care (POC)?

Correct Answer is C

Explanation

A college student comes to the school's health clinic troubled by urinary frequency and burning with right lower back pain. Which intervention should the nurse implement first?

Correct Answer is D

Explanation

A nurse is preparing to administer digoxin orally to a client. Identify the sequence of steps the nurse should take (Move the steps into the box on the right, placing them in the order of performance. Use all the steps)

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