The home health nurse is conducting an initial home visit for an infant who was recently discharged from the hospital with heart failure. During this visit, the nurse is discussing the proper administration of digoxin with the parents. Which intervention(s) should the nurse include when providing guidance to the parents? Select all that apply.

Instruct to give additional dose if the baby vomits after administration.

Demonstrate how to measure the correct amount of the oral solution.

Notify the healthcare provider before giving digoxin if your baby is ill.

Show the correct technique to obtain an apical pulse.

Administer digoxin on a strict every 12-hour schedule.

Answer and Explanation

Correct Answer : B,C,D,E

A. Instruct to give additional dose if the baby vomits after administration: Giving an extra dose after vomiting can result in digoxin toxicity because the exact amount absorbed is uncertain. Parents should never repeat a dose without consulting the healthcare provider.

B. Demonstrate how to measure the correct amount of the oral solution: Accurate measurement is critical for safe digoxin administration, as small errors can lead to underdosing or toxicity. Using an appropriate oral syringe or dropper ensures the correct dose.

C. Notify the healthcare provider before giving digoxin if your baby is ill: Illness can affect heart rate, hydration, and electrolyte balance, which increases the risk of digoxin toxicity. Parents should contact the provider to determine whether to hold or adjust the dose.

D. Show the correct technique to obtain an apical pulse: Digoxin can slow the heart rate. Parents should learn to assess the apical pulse for a full minute and understand the parameters for withholding medication based on heart rate guidelines.

E. Administer digoxin on a strict every 12-hour schedule: Maintaining consistent timing ensures stable blood levels, improving efficacy and reducing the risk of toxicity. A strict schedule is essential for therapeutic effectiveness.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

Correct Answer is A

Explanation

A. Bring a sterile chest drainage unit from central supply to the unit: This task is appropriate for delegation to a UAP because it involves transporting equipment and does not require clinical judgment or assessment.

B. Evaluate a client's urinary catheter for proper drainage: This requires assessment skills to determine whether the catheter is functioning correctly or if complications such as obstruction or infection are present.

C. Call the pharmacy to obtain a client's next antibiotic dose: Communicating directly with the pharmacy about medications is part of the nurse’s responsibilities. It involves ensuring accuracy, safety, and proper coordination of care, which cannot be delegated to unlicensed staff.

D. Observe a client's gait to determine the need for assistance: While a UAP can walk with a client or provide basic support, determining the level of assistance needed requires assessment skills. Evaluating gait involves clinical judgment and must be performed by a licensed nurse or physical therapist.

A. Encourage positive self accolades for dietary adherence. B. Determine if the client is over-hydrating to feel satiated. C. Maintain the client on an NPO status. D. Administer daily vitamin supplements.

Correct Answer is C

Explanation

A. Encourage positive self accolades for dietary adherence: While supportive reinforcement is helpful for long-term behavior change, it does not address the immediate problem of vomiting and inability to tolerate food and liquids.

B. Determine if the client is over-hydrating to feel satiated: Assessing hydration habits may be part of long-term dietary counseling, but it is not the priority intervention when the client is acutely vomiting and unable to tolerate intake.

C. Maintain the client on an NPO status: Keeping the client NPO prevents further vomiting, reduces the risk of aspiration, and allows the gastrointestinal tract to rest. This is the immediate priority intervention in managing post-bariatric surgery complications such as obstruction or delayed gastric emptying.

D. Administer daily vitamin supplements: Vitamins are important for nutritional maintenance after bariatric surgery, but administering them orally is not appropriate when the client cannot tolerate food or liquids. Nutritional support should be deferred until tolerance improves.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which task should the nurse delegate to an unlicensed assistive personnel (UAP)?

Correct Answer is A

Explanation

A client who had bariatric surgery 2 months ago is admitted because of vomiting and inability to tolerate food and liquids. The client is pain free. Which intervention should the nurse include in the client's plan of care?

Correct Answer is C

Explanation

Patient Data <pre> Exhibits <p>For each assessment finding, click to indicate whether the findings from the client's assessment are generally associated with rotator cuff injury and/or humeral fracture. Each column must have at least one response selected.</p>

A male client in the final stages of terminal cancer tells his nurse that he wishes he could just be allowed to die. The client verbalizes that he is tired of fighting this illness and is only continuing treatments because his family wants him to live. Which action should the nurse take?

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