A nurse is reviewing the medication administration record of a client who is receiving digoxin, a cardiac glycoside. The nurse notes that the client's apical pulse is 58 beats per minute. Which of the following actions should the nurse take?

Administer the medication as prescribed.

Hold the medication and notify the provider.

Check the client's blood pressure and oxygen saturation.

Repeat the apical pulse measurement after 5 minutes.

Answer and Explanation

The Correct Answer is C

Checking the client's blood pressure and oxygen saturation is an appropriate action for the nurse to take when the client's apical pulse is below 60 beats per minute, which is the lower limit of normal. This is because a low pulse rate can indicate bradycardia, which can affect the client's hemodynamic status and tissue perfusion.

A and B are incorrect. Administering the medication as prescribed or holding the medication and notifying the provider are not appropriate actions for the nurse to take without further assessment of the client's condition. Digoxin can lower the heart rate, but it can also improve cardiac output and contractility in clients with heart failure. Therefore, the nurse should not withhold the medication based on one vital sign measurement alone.

D is incorrect. Repeating the apical pulse measurement after 5 minutes is not an appropriate action for the nurse to take when the client's apical pulse is below 60 beats per minute, as it delays further assessment and intervention.

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Correct Answer is A

Explanation

A) This is correct as eating a snack before exercising can help to prevent hypoglycemia by providing glucose for energy and preventing a sudden drop in blood sugar levels.

B) This is incorrect as skipping a meal can cause hypoglycemia by depriving the body of glucose and creating an imbalance between insulin and glucose levels. Clients taking insulin should eat regular meals and snacks and monitor their blood sugar levels frequently.

C) This is incorrect as increasing the insulin dose without consulting with the provider can cause hypoglycemia by lowering the blood sugar levels too much. Stress can affect blood sugar levels in different ways depending on the type and duration of stress and the individual's response. Clients taking insulin should consult with their provider about how to adjust their insulin dose according to their stress level and blood sugar readings.

D) This is incorrect as drinking alcohol can cause hypoglycemia by inhibiting the liver's production of glucose and increasing the risk of insulin overdose. Clients taking insulin should avoid or limit alcohol intake and never drink alcohol on an empty stomach.

A. Apply a warm compress to the IV site. B. Discontinue the IV infusion and remove the catheter. C. Elevate the affected arm above the level of the heart. D. Notify the provider and document the findings.

Correct Answer is B

Explanation

B) This is correct as discontinuing the IV infusion and removing the catheter is the first action that the nurse should take when suspecting an IV site infection or phlebitis. This helps to prevent further complications and damage to the vein.

A) This is incorrect as applying a warm compress to the IV site can help to reduce inflammation and discomfort, but it is not the first action that the nurse should take. The nurse should apply a warm compress after discontinuing the IV infusion and removing the catheter.

C) This is incorrect as elevating the affected arm above the level of the heart can help to reduce swelling and improve blood flow, but it is not the first action that the nurse should take. The nurse should elevate the affected arm after discontinuing the IV infusion and removing the catheter.

D) This is incorrect as notifying the provider and documenting the findings are important steps in managing an IV site infection or phlebitis, but they are not the first actions that the nurse should take. The nurse should notify the provider and document the findings after discontinuing the IV infusion and removing the catheter.

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A nurse is reviewing the medication administration record of a client who is receiving digoxin, a cardiac glycoside. The nurse notes that the client's apical pulse is 58 beats per minute. Which of the following actions should the nurse take?

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