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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Explanation
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B. Completing a smoking cessation program is beneficial, as smoking can exacerbate symptoms of Raynaud's.
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D. Keeping the house at a cool temperature is not recommended, as cold environments can provoke Raynaud's symptoms; the client should aim to maintain a warm environment to minimize triggers.
Correct Answer is D
Explanation
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B. Phenytoin is an anticonvulsant used to prevent seizures, which may occur after a hemorrhage, but it does not address increased ICP.
C. Dopamine is used to increase blood pressure and cardiac output but does not play a role in reducing ICP.
D. Mannitol is an osmotic diuretic that helps decrease ICP by drawing fluid from brain tissue into the bloodstream, thus relieving pressure within the skull. It is the most appropriate intervention for managing increased ICP.