A nurse is preparing to administer digoxin to a client who has heart failure.
Before administering this medication, which of the following actions should the nurse take?

Check the client's blood pressure.

Measure the client's apical pulse.

Offer the client a light snack.

Weigh the client.

Answer and Explanation

The Correct Answer is B

Choice A rationale:

Checking the client's blood pressure is not the priority action when administering digoxin. Although monitoring blood pressure is essential in the overall care of a client with heart failure, the most critical parameter to assess before administering digoxin is the client's apical pulse.

Choice B rationale:

Measuring the client's apical pulse is the correct action to take before administering digoxin. Digoxin is a medication commonly prescribed for heart failure, and it has a narrow therapeutic range. It primarily works by increasing the force of the heart's contractions, and an excessively low heart rate (bradycardia) is a potential side effect of digoxin. Therefore, it is crucial to assess the client's apical pulse to ensure it is within the recommended range (usually above 60 beats per minute) before administering the medication. If the pulse rate is below the recommended range, the nurse should withhold the digoxin and notify the healthcare provider.

Choice C rationale:

Offering the client a light snack is not a necessary action before administering digoxin. While it is important to consider the client's dietary needs, it is not directly related to the administration of digoxin. However, if the client has nausea or vomiting, which can be a side effect of digoxin, a light snack might be offered after the medication.

Choice D rationale:

Weighing the client is not the immediate action to take before administering digoxin. Although daily weights can be important for assessing fluid balance in clients with heart failure, it is not the priority before administering digoxin. Monitoring the client's apical pulse is the most critical step in this context.

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Correct Answer is B

Explanation

Choice A rationale:

Extreme thirst is not a typical finding in a client with hypokalemia. Hypokalemia is an electrolyte imbalance that can lead to symptoms like weakness and irregular heartbeats, but extreme thirst is not a direct result of low potassium levels.

Choice B rationale:

"Weak, irregular pulse" is the correct response. Hypokalemia can lead to cardiac arrhythmias, which may manifest as a weak, irregular pulse. Potassium plays a crucial role in maintaining the electrical activity of the heart, and low levels can disrupt normal heart rhythms.

Choice C rationale:

Hyperactive bowel sounds are not typically associated with hypokalemia. Instead, you might expect diminished or absent bowel sounds in severe cases due to muscle weakness.

Choice D rationale:

Hyperactive reflexes are not typically associated with hypokalemia. Instead, hypokalemia can lead to muscle weakness and potentially even paralysis in severe cases.

A. Plan to have the client lay down for 1 hr after meals. B. Instruct the client to use pursed-lip breathing. C. Encourage the client to use the upper chest for respiration. D. Restrict the client's fluid intake to less than 1 Vday.

Correct Answer is B

Explanation

Choice A rationale:

Planning to have the client lay down for 1 hour after meals is not an appropriate intervention for a client with COPD. It may increase the risk of aspiration and worsen their breathing difficulties.

Choice C rationale:

Encouraging the client to use the upper chest for respiration is not the best approach for a client with COPD. Pursed-lip breathing helps improve oxygen exchange and decreases air trapping, which is more effective in managing COPD.

Choice D rationale:

Restricting the client's fluid intake to less than 1 Vday is not a suitable intervention for a client with COPD. Dehydration can lead to thicker mucus, making it harder to breathe

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A nurse is preparing to administer digoxin to a client who has heart failure.Before administering this medication, which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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A nurse is preparing to administer digoxin to a client who has heart failure.
Before administering this medication, which of the following actions should the nurse take?