The nurse prepares to administer digoxin 0.125 mg PO to a client who has chronic heart failure. The laboratory report reveals a digoxin level of 2.5 mg/mL. Which nursing action is most appropriate at this time?

Assess the apical pulse and if above 60 beats/minute administer the dose.

Administer 0.25 mcg and potassium 20 mEq IV.

Withhold the medication and notify the healthcare provider of the digoxin level.

Administer the digoxin with a potassium supplement.

Answer and Explanation

The Correct Answer is C

Choice A reason: This is incorrect. Assessing the apical pulse is not enough to determine if the client is safe to receive digoxin. The client's digoxin level is already above the therapeutic range of 0.5 to 2 ng/mL¹² and giving another dose could increase the risk of toxicity and arrhythmias.

Choice B reason: This is incorrect. Administering 0.25 mcg of digoxin and potassium 20 mEq IV is not appropriate for this client. The client does not need more digoxin or potassium, as both could worsen the client's condition. Potassium levels should be monitored closely in clients taking digoxin, as low or high levels can affect the drug's action and toxicity³.

Choice C reason: This is correct. Withholding the medication and notifying the healthcare provider of the digoxin level is the most appropriate action for this client. The client's digoxin level is dangerously high and could cause serious adverse effects such as nausea, vomiting, vision changes, bradycardia, and cardiac arrest³. The healthcare provider may order to stop digoxin temporarily, adjust the dose, or prescribe an antidote such as digoxin immune fab⁴.

Choice D reason: This is incorrect. Administering the digoxin with a potassium supplement is not advisable for this client. The client's digoxin level is already too high and adding potassium could increase the risk of hyperkalemia, which can impair the heart's electrical activity and lead to cardiac arrest³. Potassium supplements should only be given to clients with digoxin-induced hypokalemia, and only under the supervision of the healthcare provider³..

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Correct Answer is D

Explanation

Choice A reason: I will call dietary to bring you breakfast is not the best response by the nurse. This response may imply that the nurse is willing to compromise the test results or the client's safety by allowing them to eat before the test. The nurse should explain the rationale for fasting and offer the client some water or ice chips if allowed.

Choice B reason: Food may interact with the dye that is used for the test is not the best response by the nurse. This response may be partially true, but it is not specific or clear enough to justify the need for fasting. The nurse should explain that food can affect the absorption and distribution of the radioactive tracer that is injected into the bloodstream for the test, and that eating can also interfere with the quality of the images.

Choice C reason: I will ask the health care provider if the test can be rescheduled is not the best response by the nurse. This response may suggest that the nurse is not confident or knowledgeable about the test protocol or the client's condition. The nurse should explain the importance and urgency of the test and reassure the client that they will be able to eat after the test is done.

Choice D reason: The procedure is usually completed on an empty stomach is the best response by the nurse. This response is accurate and concise, and it informs the client of the standard preparation for the test. The nurse should also provide more details about the test procedure and the expected duration, and answer any questions or concerns that the client may have.

A. Be aware that pregnancy with sickle cell disease increases the risk of crisis B. Avoid travel to cities where the oxygen level is lower C. Strenuous exercise prevents the development of sickle cell crisis D. Avoid flying on commercial airlines E. Avoid drinking water on hot days.

Correct Answer is ["A","B","E"]

Explanation

Choice A reason: Pregnancy can increase the frequency and severity of sickle cell crises⁵⁶. Regular prenatal care is especially important for women with sickle cell disease⁵⁶. Therefore, it's crucial for a young female adult with sickle cell anemia to be aware that pregnancy increases the risk of crisis.

Choice B reason: Low oxygen levels can trigger a sickle cell crisis³. Therefore, avoiding travel to cities where the oxygen level is lower can help prevent crises.

Choice C reason: While regular, moderate exercise can be beneficial, strenuous exercise can lead to dehydration and fatigue, which can trigger a sickle cell crisis⁹[^10^]¹¹. Therefore, the statement that strenuous exercise prevents the development of sickle cell crisis is not accurate.

Choice D reason: Commercial airlines have controlled cabin pressure and oxygen levels, so flying is generally safe for individuals with sickle cell disease¹²³. However, it's always best to discuss travel plans with a healthcare provider³. Therefore, avoiding flying on commercial airlines is not necessarily a requirement.

Choice E reason: Dehydration can increase the risk of a sickle cell crisis, so it's important to drink plenty of fluids, especially in hot weather³.

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The nurse prepares to administer digoxin 0.125 mg PO to a client who has chronic heart failure. The laboratory report reveals a digoxin level of 2.5 mg/mL. Which nursing action is most appropriate at this time?

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Naxlex Comprehensive Predictor Exams

The client, who is scheduled for a nuclear stress test, tells the nurse that the breakfast tray was not delivered and complains of hunger. The nurse's best response is:

Correct Answer is D

Explanation

The nurse should instruct a young female adult with sickle cell anemia to do which of the following? (Select all that apply)

Correct Answer is ["A","B","E"]

Explanation

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