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A nurse is preparing to administer digoxin to a pediatric client who has heart failure. Which of the following actions is appropriate?

A.

Instructing the client to eat foods that are low in potassium.

B.

Repeat the dose if the client spits it out.

C.

Measuring apical pulse rate for 30 seconds before administration.

D.

Evaluating the client for nausea, vomiting, and anorexia.

Answer and Explanation

The Correct Answer is C

A. Clients on digoxin should actually have an adequate intake of potassium, as low potassium levels can increase the risk of digoxin toxicity.  

 

B. If a pediatric client spits out digoxin, the dose should not be repeated automatically; instead, the nurse should assess the situation and follow the facility's protocol regarding missed doses.  

 

C. Measuring the apical pulse for one full minute before administering digoxin is critical; if the pulse is below the established threshold (usually <60 bpm for children), the medication should be held and the provider notified.  

 

D. While evaluating for nausea, vomiting, and anorexia is important, it is not an appropriate immediate action before administering the medication. The priority action is to assess the apical pulse.


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View Related questions

Correct Answer is A

Explanation

A. Holding breath for 10 seconds after inhaling the medication allows for better absorption of the medication in the lungs, indicating understanding of proper inhaler technique.

B. Taking a quick inhalation is incorrect; the client should take a slow, deep breath to ensure the medication reaches the lungs effectively.

C. Waiting 10 minutes between inhalations is not necessary unless specifically instructed; usually, a second puff can be taken after 1-2 minutes if needed.

D. The client should exhale before inhaling the medication, not while it is being released; exhaling first clears the lungs for a more effective inhalation.

Correct Answer is D

Explanation

A. Avoiding all oily foods is not necessary, as dietary factors have varying effects on acne; instead, moderation is key.

B. Popping pimples can lead to scarring, infection, and further inflammation, making this an inappropriate recommendation for acne management.

C. Using strong astringents can irritate the skin and worsen acne; gentle skin care is more effective for maintaining healthy skin.

D. Washing the face with a gentle cleanser twice a day helps to remove excess oil and dirt without irritating the skin, which is the most appropriate recommendation for managing acne during puberty.

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