Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
Before administering this medication, which of the following actions should the nurse take?
A. Check the client's blood pressure.
Checking the client's blood pressure is not the priority action when administering digoxin. Although monitoring blood pressure is essential in the overall care of a client with heart failure, the most critical parameter to assess before administering digoxin is the client's apical pulse.
B. Measure the client's apical pulse.
Measuring the client's apical pulse is the correct action to take before administering digoxin. Digoxin is a medication commonly prescribed for heart failure, and it has a narrow therapeutic range. It primarily works by increasing the force of the heart's contractions, and an excessively low heart rate (bradycardia) is a potential side effect of digoxin. Therefore, it is crucial to assess the client's apical pulse to ensure it is within the recommended range (usually above 60 beats per minute) before administering the medication. If the pulse rate is below the recommended range, the nurse should withhold the digoxin and notify the healthcare provider.
C. Offer the client a light snack.
Offering the client a light snack is not a necessary action before administering digoxin. While it is important to consider the client's dietary needs, it is not directly related to the administration of digoxin. However, if the client has nausea or vomiting, which can be a side effect of digoxin, a light snack might be offered after the medication.
D. Weigh the client.
Weighing the client is not the immediate action to take before administering digoxin. Although daily weights can be important for assessing fluid balance in clients with heart failure, it is not the priority before administering digoxin. Monitoring the client's apical pulse is the most critical step in this context.
This question is an excerpt from Nurse Dive's nursing test bank - ATI Custom Fall NS 126 Proctored Exam 1. Take the full exam now
Full Explanation
Choice A rationale:
Checking the client's blood pressure is not the priority action when administering digoxin. Although monitoring blood pressure is essential in the overall care of a client with heart failure, the most critical parameter to assess before administering digoxin is the client's apical pulse.
Choice B rationale:
Measuring the client's apical pulse is the correct action to take before administering digoxin. Digoxin is a medication commonly prescribed for heart failure, and it has a narrow therapeutic range. It primarily works by increasing the force of the heart's contractions, and an excessively low heart rate (bradycardia) is a potential side effect of digoxin. Therefore, it is crucial to assess the client's apical pulse to ensure it is within the recommended range (usually above 60 beats per minute) before administering the medication. If the pulse rate is below the recommended range, the nurse should withhold the digoxin and notify the healthcare provider.
Choice C rationale:
Offering the client a light snack is not a necessary action before administering digoxin. While it is important to consider the client's dietary needs, it is not directly related to the administration of digoxin. However, if the client has nausea or vomiting, which can be a side effect of digoxin, a light snack might be offered after the medication.
Choice D rationale:
Weighing the client is not the immediate action to take before administering digoxin. Although daily weights can be important for assessing fluid balance in clients with heart failure, it is not the priority before administering digoxin. Monitoring the client's apical pulse is the most critical step in this context.
Similar Questions
A nurse is reinforcing teaching with a client who is taking hydrochlorothiazide.
Which of the following information should the nurse include in the teaching?
A. Take the medication on an empty stomach.
Taking hydrochlorothiazide on an empty stomach is not a requirement for this medication. Hydrochlorothiazide is a diuretic used to treat conditions like hypertension and edema. It can be taken with or without food, and food may help reduce stomach upset for some individuals.
B. Muscle weakness is an expected adverse effect.
Muscle weakness is an adverse effect of hydrochlorothiazide. Therefore, it is not an expected outcome. Hydrochlorothiazide is a thiazide diuretic, and one of its common side effects is potassium loss through increased urine output. This can lead to muscle weakness and cramping. The nurse should educate the client about the signs and symptoms of low potassium and the importance of including potassium-rich foods in their diet.
C. Increase daily intake of foods high in potassium.
Increasing daily intake of foods high in potassium is essential information to include in the teaching for a client taking hydrochlorothiazide. Thiazide diuretics like hydrochlorothiazide can cause potassium depletion, which may result in adverse effects like muscle weakness, cramping, and cardiac dysrhythmias. Therefore, advising the client to consume potassium-rich foods, such as bananas, oranges, and potatoes, can help counteract the potassium loss associated with the medication.
D. Take the medication at bedtime.
Taking the medication at bedtime is not a specific requirement for hydrochlorothiazide. Thiazide diuretics can be taken at various times of the day, depending on the client's preferences and when they are most compliant with their medication regimen. The timing of administration should be consistent to maintain the medication's effectiveness.
Full Explanation
Choice A rationale:
Taking hydrochlorothiazide on an empty stomach is not a requirement for this medication. Hydrochlorothiazide is a diuretic used to treat conditions like hypertension and edema. It can be taken with or without food, and food may help reduce stomach upset for some individuals.
Choice B rationale:
Muscle weakness is an adverse effect of hydrochlorothiazide. Therefore, it is not an expected outcome. Hydrochlorothiazide is a thiazide diuretic, and one of its common side effects is potassium loss through increased urine output. This can lead to muscle weakness and cramping. The nurse should educate the client about the signs and symptoms of low potassium and the importance of including potassium-rich foods in their diet.
Choice C rationale:
Increasing daily intake of foods high in potassium is essential information to include in the teaching for a client taking hydrochlorothiazide. Thiazide diuretics like hydrochlorothiazide can cause potassium depletion, which may result in adverse effects like muscle weakness, cramping, and cardiac dysrhythmias. Therefore, advising the client to consume potassium-rich foods, such as bananas, oranges, and potatoes, can help counteract the potassium loss associated with the medication.
Choice D rationale:
Taking the medication at bedtime is not a specific requirement for hydrochlorothiazide. Thiazide diuretics can be taken at various times of the day, depending on the client's preferences and when they are most compliant with their medication regimen. The timing of administration should be consistent to maintain the medication's effectiveness.
A nurse is collecting data from a client who has a sodium level of 128 mEq/L. Which of the following manifestations should the nurse expect?
A. Hyporeflexia.
Hyporeflexia refers to diminished or absent reflexes. While hyponatremia can affect neurological function, hyporeflexia is not a typical manifestation. Instead, hyperreflexia may occur in severe cases due to cerebral edema and increased intracranial pressure.
B. Constipation.
Constipation is not a common manifestation of hyponatremia. Gastrointestinal symptoms such as nausea, vomiting, and abdominal cramping may occur, but constipation is not typically associated with sodium imbalances.
C. Increased appetite.
Hyponatremia does not typically cause increased appetite. Instead, gastrointestinal symptoms such as nausea and anorexia are more commonly observed. Increased appetite is not directly related to sodium levels but may be seen in conditions such as hyperthyroidism or certain medications.
D. Headache.
Hyponatremia, defined as a serum sodium level below 135 mEq/L, can lead to various neurological symptoms due to the altered osmotic pressure in the brain cells. When the sodium level drops below normal, water moves into the cells, causing them to swell, which can lead to increased intracranial pressure and subsequent headaches. Therefore, a client with a sodium level of 128 mEq/L is likely to experience headaches as a manifestation of hyponatremia.
Full Explanation
The correct answer is Choice D: Headache.
Rationale for Choice D (Headache): Hyponatremia, defined as a serum sodium level below 135 mEq/L, can lead to various neurological symptoms due to the altered osmotic pressure in the brain cells. When the sodium level drops below normal, water moves into the cells, causing them to swell, which can lead to increased intracranial pressure and subsequent headaches. Therefore, a client with a sodium level of 128 mEq/L is likely to experience headaches as a manifestation of hyponatremia.
Rationale for other choices:
Choice A: Hyporeflexia Hyporeflexia refers to diminished or absent reflexes. While hyponatremia can affect neurological function, hyporeflexia is not a typical manifestation. Instead, hyperreflexia may occur in severe cases due to cerebral edema and increased intracranial pressure.
Choice B: Constipation Constipation is not a common manifestation of hyponatremia. Gastrointestinal symptoms such as nausea, vomiting, and abdominal cramping may occur, but constipation is not typically associated with sodium imbalances.
Choice C: Increased appetite Hyponatremia does not typically cause increased appetite. Instead, gastrointestinal symptoms such as nausea and anorexia are more commonly observed. Increased appetite is not directly related to sodium levels but may be seen in conditions such as hyperthyroidism or certain medications.
Therefore, based on the provided data and typical manifestations of hyponatremia, the correct answer is Choice D: Headache. This is because headaches are a common neurological symptom associated with low sodium levels and increased intracranial pressure.
A nurse is conducting a preoperative interview with a client who is scheduled for surgery.
The client states that he takes acetylsalicylic acid 81 mg. by mouth daily.
Prior to the client's upcoming surgery, the nurse should instruct the client to do which of the following?
A. Discontinue the dose 2 weeks before surgery.
The nurse should instruct the client to discontinue the dose of acetylsalicylic acid (aspirin) 2 weeks before surgery. Aspirin is an antiplatelet medication that can increase the risk of bleeding during and after surgery. Discontinuing it before surgery helps reduce the risk of excessive bleeding during the procedure. The recommended time frame for discontinuation may vary based on the patient's surgical procedure and the surgeon's preferences. However, 2 weeks is a common guideline to ensure that the antiplatelet effects of aspirin have diminished.
B. Decrease the dose by half 2 weeks before surgery.
Decreasing the dose by half 2 weeks before surgery may not be sufficient to minimize the risk of bleeding associated with aspirin. It is generally recommended to discontinue the medication completely to ensure that the antiplatelet effect has worn off.
C. Take the originally prescribed dose the week of surgery.
Taking the originally prescribed dose of aspirin the week of surgery is not advisable because it can increase the risk of bleeding during the surgical procedure. It is important to discontinue aspirin well before the surgery.
D. Double the dose the week of surgery.
Doubling the dose of aspirin the week of surgery is contraindicated as it can significantly increase the risk of bleeding. This choice is not recommended in the context of preoperative management.
Full Explanation
Choice A rationale:
The nurse should instruct the client to discontinue the dose of acetylsalicylic acid (aspirin) 2 weeks before surgery. Aspirin is an antiplatelet medication that can increase the risk of bleeding during and after surgery. Discontinuing it before surgery helps reduce the risk of excessive bleeding during the procedure. The recommended time frame for discontinuation may vary based on the patient's surgical procedure and the surgeon's preferences. However, 2 weeks is a common guideline to ensure that the antiplatelet effects of aspirin have diminished.
Choice B rationale:
Decreasing the dose by half 2 weeks before surgery may not be sufficient to minimize the risk of bleeding associated with aspirin. It is generally recommended to discontinue the medication completely to ensure that the antiplatelet effect has worn off.
Choice C rationale:
Taking the originally prescribed dose of aspirin the week of surgery is not advisable because it can increase the risk of bleeding during the surgical procedure. It is important to discontinue aspirin well before the surgery.
Choice D rationale:
Doubling the dose of aspirin the week of surgery is contraindicated as it can significantly increase the risk of bleeding. This choice is not recommended in the context of preoperative management.