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 C
Explanation
A. Advise the client to come into the office. The client needs immediate emergency intervention, not a routine office visit.
B. Advise the client to take an antacid. Chest pain unrelieved by nitroglycerin may indicate myocardial infarction; an antacid would not help.
C. Instruct the client to call 911. Persistent chest pain unrelieved by nitroglycerin warrants emergency attention due to potential heart attack.
D. Tell the client to take another nitroglycerin tablet in 15 min. The protocol allows taking an additional dose in 5 minutes, but emergency services should be called for unrelieved chest pain.
Correct Answer is B
Explanation
A. Slow: Atrial fibrillation typically leads to an irregular, often rapid pulse, not necessarily slow.
B. Irregular: Atrial fibrillation causes an irregular pulse due to uncoordinated atrial contractions.
C. Bounding: A bounding pulse is associated with conditions like high cardiac output or fluid overload, not atrial fibrillation.
D. Not palpable: The pulse in atrial fibrillation is usually palpable but irregular.