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 B
Explanation
A. Warm extremities. PAD typically leads to cold extremities due to poor blood flow.
B. Intermittent claudication. Intermittent claudication, or muscle pain during exercise, is a classic symptom of PAD caused by limited blood supply to the muscles.
C. Darkened skin color near extremities. Darkened skin is more common in venous insufficiency, not PAD. PAD can cause pale or bluish skin.
D. Edema. Edema is typically associated with venous insufficiency, not PAD.
Correct Answer is D
Explanation
A. Creatinine phosphokinase (CPK): CPK levels peak within 24 hours after an MI and return to normal within 2-3 days.
B. Myoglobin: Myoglobin rises within hours but returns to normal within 24 hours after MI.
C. Creatinine kinase-MB (CK-MB): CK-MB peaks 12-24 hours post-MI and returns to baseline within 2-3 days.
D. Troponin T: Troponin T remains elevated for up to 10-14 days after an MI, providing long-term evidence of myocardial injury.