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 a safe practice that helps prevent burns, which is important for clients with PVD who may have reduced sensation.
B. Wearing stockings with elastic tops can restrict blood flow and is generally not recommended for clients with PVD; clients should use non-restrictive stockings instead.
C. Not going barefoot is a good practice to prevent injuries and ulcers, which are risks for clients with PVD.
D. Avoiding crossing the legs is advisable as it helps maintain adequate blood flow and reduces the risk of circulation problems.
Correct Answer is ["B","C","D","E"]
Explanation
A. Family history is a non-modifiable risk factor as it cannot be changed or controlled.
B. A sedentary lifestyle is a modifiable risk factor; increasing physical activity can reduce the risk of heart disease.
C. Smoking is a modifiable risk factor; quitting smoking can significantly decrease the risk of heart disease.
D. Diabetes can be managed and controlled through lifestyle changes and medication, making it a modifiable risk factor.
E. Hypertension is also a modifiable risk factor; it can be managed through diet, exercise, and medication.