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.
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 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.
Correct Answer is D
Explanation
A. Barrel chest. A barrel chest is commonly seen in chronic obstructive pulmonary disease (COPD) rather than mitral valve stenosis.
B. Bradycardia. Bradycardia is not typically associated with mitral valve stenosis, as symptoms often include rapid or irregular heartbeat.
C. Clubbing of the fingers. Clubbing is associated with chronic hypoxia, often due to pulmonary conditions, not specifically with mitral valve stenosis.
D. Heart murmur. Mitral valve stenosis causes turbulent blood flow through the narrowed valve, resulting in a characteristic murmur.