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. Bounding peripheral pulses: Hypokalemia typically causes weak, thready pulses rather than bounding ones.
B. Decreased deep-tendon reflexes: Hypokalemia can cause muscle weakness and decreased deep-tendon reflexes due to impaired neuromuscular function.
C. Hyperactive bowel sounds: Hypokalemia generally causes decreased or hypoactive bowel sounds due to slowed smooth muscle contraction.
D. Restlessness: Restlessness is not a typical sign of hypokalemia; hypokalemia more commonly causes weakness, lethargy, or fatigue.
Correct Answer is A
Explanation
A. To prevent blood clotting: Aspirin is an antiplatelet agent, and it reduces blood clot formation, which helps prevent further cardiac events after an MI.
B. To reduce inflammation: Although aspirin has anti-inflammatory properties, this is not the primary reason for its use in post-MI clients.
C. To prevent fever: Aspirin can reduce fever, but this is not its purpose in MI prevention.
D. To provide analgesia: Aspirin can relieve pain, but in this context, it is used to prevent blood clotting, not as an analgesic.