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","B","C","E"]

Explanation

A) This is correct as checking the medication label against the MAR three times is one of the six rights of medication administration and helps to ensure accuracy and safety.

B) This is correct as using two client identifiers is another one of the six rights of medication administration and helps to verify the identity of the client.

C) This is correct as asking the client to state their name and date of birth is another way of verifying the identity of the client and can also help to engage them in their care.

D) This is incorrect as documenting the medication administration should be done as soon as possible after giving the medication to avoid errors and omissions.

E) This is correct as following the six rights of medication administration (right client, right medication, right dose, right route, right time, right documentation) is a standard practice that helps to prevent medication errors.

A. "I should eat a snack before exercising." B. "I should skip a meal if my blood sugar is high." C. "I should increase my insulin dose if I am stressed." D. "I should drink alcohol only on special occasions."

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.

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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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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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