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. Decreasing activity is not recommended for peripheral venous disease; clients are encouraged to engage in physical activity to promote circulation and prevent complications.
B. Massaging legs may not be advisable as it could exacerbate swelling and discomfort; instead, elevation is often recommended.
C. Inspecting legs daily for changes is essential for early detection of complications such as skin changes or ulcers, indicating the client understands the importance of monitoring their condition.
D. Keeping legs in a dependent position can worsen venous pooling and swelling; elevation is generally recommended to improve venous return.
Correct Answer is B
Explanation
A. The ascending tracts transmit sensory information to the brain, but they do not process the information; that function is performed in the brain itself.
B. This statement accurately reflects the function of the descending tracts, which carry motor signals from the CNS to the muscles, facilitating voluntary movement.
C. Sensory receptors are located in various tissues throughout the body, including the skin and muscles, but not exclusively in the muscles.
D. Motor neurons are located in the spinal cord and peripheral nervous system, not in the dermal layer of the skin, where sensory receptors reside.