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 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.

A. The client's international normalized ratio (INR) level B. The client's use of herbal supplements C. The client's intake of vitamin K-rich foods D. The client's history of peptic ulcer disease E. The client's blood pressure

Correct Answer is ["A","B","D"]

Explanation

A) This is correct as the INR level measures how long it takes for blood to clot and is used to monitor the effectiveness and safety of warfarin therapy. A high INR level indicates a higher risk of bleeding.

B) This is correct as some herbal supplements, such as garlic, ginger, ginkgo, and ginseng, can interact with warfarin and increase the risk of bleeding.

C) This is incorrect as vitamin K-rich foods, such as green leafy vegetables, can interfere with warfarin and decrease its effectiveness, leading to a lower risk of bleeding. However, clients taking warfarin should maintain a consistent intake of vitamin K-rich foods and avoid sudden changes in their diet.

D) This is correct as peptic ulcer disease is a condition that causes erosion and inflammation of the lining of the stomach or duodenum and can lead to bleeding complications, especially when taking warfarin.

E) This is incorrect as blood pressure does not directly affect the risk of bleeding from warfarin therapy. However, clients taking warfarin should monitor their blood pressure regularly and report any signs of hypertension or hypotension to their provider.

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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 caring for a client who is receiving intravenous (IV) fluids. The nurse notices that the IV site is red, swollen, and painful. Which of the following actions should the nurse take first?

Correct Answer is B

Explanation

A nurse is reviewing a client's medication list and notices that the client is taking warfarin, a blood thinner. Which of the following factors should the nurse assess as potential risk factors for bleeding? (Select all that apply.)

Correct Answer is ["A","B","D"]

Explanation

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