A nurse is assisting in the plan of care for a client who is receiving digoxin to treat heart failure. Which of the following actions should the nurse plan to take?
Measure the client's apical pulse rate for 30 seconds before administration.
Withhold the medication if the client's heart rate is above 100/min.
Instruct the client to eat foods that are low in potassium.
Monitor the client for nausea, vomiting, and yellow vision.
The Correct Answer is D
A. The nurse should measure the apical pulse for a full minute (not 30 seconds) before administering digoxin. If the pulse is below 60 beats per minute, the medication should be withheld, making this option incomplete.
B. Digoxin should be withheld if the heart rate is below 60/min, not above 100/min. This statement does not reflect proper nursing protocol.
C. Clients taking digoxin should maintain adequate potassium levels, so advising low potassium intake is incorrect. Foods rich in potassium are encouraged.
D. Monitoring for symptoms such as nausea, vomiting, and yellow vision is essential, as these may indicate digoxin toxicity, making this option correct.
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Correct Answer is C
Explanation
A. Wearing low-heeled shoes is advisable to promote better posture and alignment, so this statement is appropriate.
B. Carrying heavy objects close to the body is a recommended practice for preventing back injury, indicating correct understanding.
C. Sitting with knees lower than hips can lead to poor posture and increased strain on the lower back, indicating a need for further clarification. The correct position should have the knees level or slightly higher than the hips.
D. Strengthening abdominal muscles is beneficial for back support and injury prevention, indicating the client understands the concept.
Correct Answer is D
Explanation
A. Black cohosh is primarily used for menopausal symptoms and does not have benefits for peripheral arterial disease.
B. Echinacea is commonly used to boost the immune system but is not effective for improving circulation or walking distance in peripheral arterial disease.
C. Saw palmetto is mainly used for urinary symptoms related to benign prostatic hyperplasia and does not address the symptoms of peripheral arterial disease.
D. Ginkgo biloba has been shown to improve blood circulation and may help increase pain-free walking distance in clients with peripheral arterial disease, making it the most suitable option.