A nurse is caring for a client who is postoperative following an appendectomy.

Vital Signs

1800:

Temperature 98.4° F (36.8° C) Heart rate 104/min

Respiratory rate 22/min

Blood pressure 142/80 mm Hg

O2 saturation 97% on room air

1800:

Client alert and oriented x 4

Skin warm and dry

Lungs clear on auscultation

Bowel sounds hypoactive in all four quadrants Urine clear yellow

Incisional dressing clean and dry

Client reports pain as 6 on a scale of 0 to 10

1815:

Morphine administered as prescribed

2000:

Temperature 98.4° F (36.8° C) Heart rate 110/min Respiratory rate 24/min

Blood pressure 158/88 mm Hg O2 saturation 93% on room air

Which of the following 4 client findings should the nurse report to the provider?

A. Remove indwelling urinary catheter when no longer indicated: This action prevents urinary tract infections and promotes bladder function.

B. Elevate affected limb at chest level: This action is contraindicated because it increases venous pressure and edema in the affected extremity, which could compromise blood flow and nerve function.
C. Assist the adolescent with ambulation from bed to chair: This action prevents complications such as deep vein thrombosis, pulmonary embolism, pneumonia, and constipation by enhancing circulation, respiration, and bowel motility.
D. Perform neurovascular assessments every hour: This action monitors for signs of impaired blood flow or nerve function in the affected extremity, such as changes in color, temperature, sensation, movement, or pulse.
E. Apply warm packs to right extremity for the first 24hrs: This action is contraindicated because it increases blood flow and edema in the affected extremity, which could compromise blood flow and nerve function.

Choice A reason:

"Repeat the dose if your child vomits within 1 hour after taking the medication." This statement is incorrect. If a child vomits within 1 hour after taking digoxin, the parents should not repeat the dose. The reason is that the child may have already absorbed a sufficient amount of the medication before vomiting, and an additional dose could lead to digoxin toxicity.

Choice B reason:

"You can add the medication to a half-cup of your child's favourite juice." This statement is incorrect. Adding digoxin to juice or any other food or drink is not recommended. Digoxin should be administered separately and not mixed with food or liquids to ensure accurate dosing and prevent potential interactions with other substances.

Choice C reason:

"Have your child drink a small glass of water after swallowing the medication." This statement is correct. Giving a small glass of water after administering digoxin helps ensure that the medication is fully swallowed and goes into the stomach, reducing the risk of it being retained in the mouth or throat.

Choice D reason:

"Limit your child's potassium intake while she is taking this medication." This statement is not accurate. Digoxin is often prescribed in conjunction with other heart failure medications, some of which may impact potassium levels. However, the parents should not arbitrarily limit the child's potassium intake without specific instructions from the healthcare provider. The healthcare provider will monitor the child's potassium levels and adjust the treatment plan as necessary.