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 B
Explanation
A. Using a thermometer to check the temperature of bath water is important for clients with PVD to prevent burns, indicating that this statement reflects understanding.
B. Wearing stockings with elastic tops is not recommended for clients with PVD as they can restrict blood flow and exacerbate symptoms. This indicates a need for further teaching.
C. The statement about not going barefoot is correct, as it helps prevent injury, which is crucial for clients with PVD.
D. Avoiding crossing legs is a proper action to promote circulation and prevent vascular complications, showing the client’s understanding of their condition.
Correct Answer is ["B","C","D"]
Explanation
A. Varicose veins are typically associated with venous insufficiency rather than coronary artery disease.
B. Chest pain, or angina, is a common symptom of coronary artery disease due to reduced blood flow to the heart muscle.
C. Palpitations can occur in clients with coronary artery disease as the heart compensates for decreased perfusion.
D. Shortness of breath can result from decreased cardiac output and oxygenation due to coronary artery disease.
E. A heart murmur is not a typical manifestation of coronary artery disease; it is more associated with valvular heart disease.