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","C","E"]

Explanation

B) This is correct as mixing medications with food or liquids that are easy to swallow can help to prevent choking and aspiration and improve compliance. However, some medications may interact with certain foods or liquids, so the nurse should check with the pharmacist before mixing them.

C) This is correct as giving one medication at a time and allowing time for swallowing can help to prevent choking and aspiration and ensure that each medication is taken correctly. The nurse should also monitor the client for signs of difficulty swallowing, such as coughing, gagging, drooling, or regurgitation.

E) This is correct as assessing the client's mouth for pocketing of medications can help to prevent medication errors and ensure that each medication is taken correctly. Pocketing of medications occurs when the client holds medications in their cheeks or under their tongue instead of swallowing them. This can lead to ineffective therapy, toxicity, or adverse effects.

A) This is incorrect as crushing or dissolving tablets and capsules before giving them to the client can alter their effectiveness, absorption, or bioavailability and cause medication errors or adverse effects. Some tablets and capsules are designed to be swallowed whole, such as enteric-coated, extended-release, or sublingual formulations. The nurse should check with the pharmacist before crushing or dissolving any tablets or capsules.

D) This is incorrect as encouraging the client to drink water before and after taking medications can help to prevent choking and aspiration and ensure adequate hydration, but it may not be appropriate for some clients who have dysphagia or who are on fluid restrictions. The nurse should assess the client's ability to drink water safely and follow their individualized plan of care.

A. Check the medication label against the medication administration record (MAR) three times. B. Use two client identifiers before giving the medication. C. Ask the client to state their name and date of birth before giving the medication. D. Document the medication administration after completing other tasks. E. Follow the six rights of medication administration.

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.

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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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