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.
Free Nursing Test Bank
- Free Pharmacology Quiz 1
- Free Medical-Surgical Quiz 2
- Free Fundamentals Quiz 3
- Free Maternal-Newborn Quiz 4
- Free Anatomy and Physiology Quiz 5
- Free Obstetrics and Pediatrics Quiz 6
- Free Fluid and Electrolytes Quiz 7
- Free Community Health Quiz 8
- Free Promoting Health across the Lifespan Quiz 9
- Free Multidimensional Care Quiz 10
View Related questions
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 C
Explanation
A. The recommended sodium intake for individuals with hypertension is typically less than 2,300 mg per day, so a goal of 3,000 mg is too high.
B. For individuals with hypertension, it is recommended to limit alcohol consumption to 1 drink per day for women and 2 drinks per day for men, so 3 drinks is excessive.
C. Planning to have potassium blood levels checked when taking thiazide diuretics is important because these medications can lead to hypokalemia (low potassium levels), making this the correct response.
D. Setting a goal body weight within 25% of ideal body weight is not a standard recommendation; weight management should focus on achieving a healthy weight, rather than a specific percentage of ideal body weight.