A nurse is caring for a client who has heart failure and has been taking digoxin 0.25 mg daily. The client refuses breakfast and reports nausea. Which of the following actions should the nurse take first?
Suggest that the client rests before eating the meal.
Check the client's vital signs.
Request a dietary consult.
Request an order for an antiemetic.
The Correct Answer is B
A. Suggest that the client rests before eating the meal. Although rest can help with nausea, it does not address the potential issue of digoxin toxicity, which can cause nausea.
B. Check the client's vital signs. Checking vital signs, especially heart rate, is the priority because nausea can indicate digoxin toxicity, which affects heart function.
C. Request a dietary consult. A dietary consult may be helpful if the client continues to refuse meals, but it does not address the immediate potential for digoxin toxicity.
D. Request an order for an antiemetic. Although an antiemetic may help with nausea, assessing for toxicity takes priority.
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Correct Answer is A
Explanation
A. Shortness of breath while lying down. Shortness of breath when lying down, or orthopnea, is common in left-sided heart failure due to fluid backing up into the lungs, causing pulmonary congestion.
B. Jugular venous distention. Jugular venous distention is more commonly associated with right-sided heart failure due to systemic venous congestion.
C. Right upper quadrant pain. Right upper quadrant pain is associated with liver congestion due to right-sided heart failure, not left-sided heart failure.
D. Pitting edema of the lower legs. Pitting edema is a symptom of right-sided heart failure, as fluid backs up into the peripheral circulation.
Correct Answer is B
Explanation
A. Enriched cereal in whole milk. Whole milk is high in saturated fats, which the DASH diet aims to limit.
B. Turkey sandwich on whole wheat bread, green beans, and banana. This meal is balanced, low in saturated fats, high in fiber, and aligns well with the DASH diet principles.
C. Pork sausage and baked beans. Pork sausage is high in saturated fats and sodium, which should be limited in the DASH diet.
D. Hamburger, steak fries, and an orange. While the orange is DASH-friendly, the hamburger and fries are high in fats and sodium.