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 C

Explanation

The correct answer is choice C: “I will follow a diet high in calories and protein.”

Here are the rationales for each choice:

Choice A rationale:“I will drink about 34 ounces of fluid every day.” While staying hydrated is important for overall health, this statement does not specifically address a key self-management strategy for emphysema. Adequate fluid intake can help thin mucus, making it easier to expel, but it is not the most critical aspect of managing emphysema.

Choice B rationale:“I will inhale slowly through pursed lips to help me breathe better.” This statement is incorrect because the correct technique is toexhalethrough pursed lips, not inhale. Pursed-lip breathing helps to keep the airways open longer, reduce shortness of breath, and improve the exchange of oxygen and carbon dioxide.

Choice C rationale:“I will follow a diet high in calories and protein.” This is the correct answer. Emphysema can increase the body’s energy expenditure due to the effort required for breathing. A diet high in calories and protein helps maintain muscle mass and provides the necessary energy to support respiratory function.

Choice D rationale:“I will lie on my stomach to practice abdominal breathing every day.” This statement is not recommended for emphysema management. While abdominal or diaphragmatic breathing can be beneficial, lying on the stomach is not a typical position for practicing this technique. It is usually done while sitting or lying on the back.

A. Heart rate 50/min. B. Respiratory rate 18/min. C. Oxygen saturation 95%. D. Blood pressure 160/94 mm Hg.

Correct Answer is A

Explanation

The correct answer is choiceA. Heart rate 50/min.

Choice A rationale:

Atenolol is a beta-blocker that can significantly lower heart rate.A heart rate of 50/min is considered bradycardia (slow heart rate), and administering atenolol could further decrease the heart rate to a dangerously low level. Therefore, the nurse should withhold the medication in this case.

Choice B rationale:

A respiratory rate of 18/min is within the normal range (12-20 breaths per minute) and does not contraindicate the use of atenolol. Therefore, this finding would not require withholding the medication.

Choice C rationale:

An oxygen saturation of 95% is within the normal range (typically 95-100%) and does not contraindicate the use of atenolol. Thus, this finding would not necessitate withholding the medication.

Choice D rationale:

While a blood pressure of 160/94 mm Hg indicates hypertension, atenolol is often prescribed to manage high blood pressure. Therefore, this finding would not require withholding the medication.

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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?

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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?