A nurse is reviewing the prescriptions for a client who is pregnant and is taking digoxin. Which of the following actions should the nurse take to best evaluate the client's medication adherence?
Ask the client if they are taking the medication as prescribed.
Determine the client's apical pulse rate.
Check the client's serum medication level.
Assess the client's kidney function.
The Correct Answer is C
Explanation
Choice A Reason:
While asking the client can provide some information, it relies on self-reporting, which may not always be accurate. Clients might forget doses, misunderstand instructions, or provide inaccurate information, whether intentional or unintentional. Therefore, this method is not the most reliable way to assess medication adherence.
Choice B Reason:
Digoxin can affect the heart rate, so checking the apical pulse is important for monitoring potential side effects, such as bradycardia. However, the pulse rate alone does not provide direct evidence of whether the client is taking the medication consistently or correctly. The pulse can be influenced by various factors and may not accurately reflect medication adherence.
Choice C Reason:
Checking the serum medication level provides an objective measurement of whether the client is taking digoxin as prescribed. This is a direct indicator of medication adherence and is particularly important for a medication like digoxin, which requires precise dosing to avoid toxicity or subtherapeutic effects.
Choice D Reason:
Assessing kidney function is crucial when managing a client on digoxin because impaired kidney function can lead to digoxin toxicity. However, this assessment does not directly measure whether the client is taking the medication as prescribed. It's more about ensuring the safe use of the drug rather than evaluating adherence.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Explanation
Choice A Reason:
Reporting the guardian's refusal of the medication to social services is incorrect. Refusing a medication for a newborn, especially one that is standard practice like erythromycin ophthalmic ointment, does not automatically warrant reporting to social services. Reporting to social services should only occur in cases where there are concerns for the safety or well-being of the newborn.
Choice B Reason:
Documenting the guardian's refusal of the medication. Is correct. When a guardian refuses a prescribed medication for a newborn, the nurse's immediate responsibility is to document this refusal accurately in the medical record. Documentation ensures that the refusal is well-documented for future reference and legal purposes.
Choice C Reason:
Informing the guardian that the medication can be given after discharge is incorrect. While it's important to educate the guardian about the purpose and benefits of the medication, informing them that it can be given after discharge may not address the immediate need for prophylaxis against ophthalmia neonatorum, which is the infection erythromycin ophthalmic ointment is intended to prevent.
Choice D Reason:
Notifying the facility's ethics committee about the guardian's medication refusal is incorrect. In most cases, notifying the ethics committee would be an overreaction to a guardian's refusal of a standard prophylactic medication. Ethics committees are typically reserved for complex ethical dilemmas that require deliberation and guidance beyond standard practice.
Correct Answer is C
Explanation
Explanation
Choice A Reason:
A heart rate of 89 beats per minute is within the normal range for a postpartum client and does not typically require immediate intervention. However, the nurse should continue to monitor the client's vital signs for any significant changes.
Choice B Reason:
Blood pressure of 120/70 mm Hg is within the normal range for a postpartum client and does not typically require immediate intervention. However, as with other vital signs, ongoing monitoring is essential.
Choice C Reason:
Cool, clammy skin can be indicative of hypovolemia or shock, which can occur postpartum due to excessive bleeding (hemorrhage) or other complications. Therefore, this finding should be reported to the provider promptly for further evaluation and intervention to prevent potential complications.
Choice D Reason:
Moderate lochia serosa is incorrect. Lochia serosa, which is the pinkish-brown vaginal dis charge occurring 3 to 10 days postpartum, is considered normal. Moderate lochia serosa is also within the expected range for this stage of postpartum recovery and does not require immediate intervention. However, if lochia becomes excessive, foul-smelling, or accompanied by signs of infection, it should be reported to the provider for further evaluation.
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