The nurse is reinforcing teaching with a client who has a new prescription for digoxin to treat heart failure. Which of the following instructions should the nurse include?

Check the pulse rate for 30 seconds and multiply the result by 2

Increase intake of sodium

Contact the health care provider for heart rate less than 60/min

Take the medication with food if you develop nausea

Answer and Explanation

The Correct Answer is C

A. Checking the pulse rate for 30 seconds and multiplying by 2 may not be accurate enough for a medication like digoxin, which requires precise monitoring.
B. Increasing sodium intake is not recommended for heart failure patients as it can worsen fluid retention and exacerbate symptoms.
C. Digoxin can cause bradycardia; therefore, it is crucial for clients to monitor their heart rate and contact their healthcare provider if it falls below 60/min to avoid adverse effects.
D. Taking digoxin with food can help with nausea but is not as critical as monitoring heart rate for potential toxicity.

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Correct Answer is A

Explanation

A. A PRN order is given as needed, based on the patient's condition or request.
B. A STAT order is for immediate administration.
C. A one-time order is for a single, specific instance.
D. A standing order is a pre-established and approved set of instructions for specific situations.

A. The patient is having a mild reaction that can be treated easily with an antihistamine. B. The patient is experiencing a moderate allergic reaction and should improve shortly. C. The patient is having an anaphylactic reaction and emergency interventions should be started. D. These symptoms are probably due to food poisoning because very few patients have true allergic responses.

Correct Answer is C

Explanation

A. While itching and hives can be signs of a mild allergic reaction, difficulty breathing and low blood pressure indicate a more severe issue. Treating a severe reaction as mild can delay necessary emergency interventions, potentially leading to life-threatening consequences.
B. The symptoms described, including difficulty breathing and hypotension, suggest a severe, not moderate, allergic reaction. This misjudgment can result in insufficient treatment and delay life-saving measures.
C. Anaphylactic reactions are characterized by symptoms such as hives, difficulty breathing, and low blood pressure, requiring immediate emergency treatment. Prompt recognition and intervention are critical to prevent severe complications or death.
D. Food poisoning typically presents with gastrointestinal symptoms rather than respiratory distress and hypotension. Misdiagnosing an anaphylactic reaction as food poisoning can prevent timely administration of appropriate treatments like epinephrine.

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The nurse is reinforcing teaching with a client who has a new prescription for digoxin to treat heart failure. Which of the following instructions should the nurse include?

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