Practice Question
A nurse is caring for a client who has congestive heart failure and is taking digoxin daily. The client refused breakfast and is complaining of nausea and weakness. Which of the following actions should the nurse take first?
Answer Choices:
Correct Answer:
Check the client's vital signs.
Rationale:
📌Nausea, weakness, and anorexia are early signs of digoxin toxicity, which can lead to life-threatening arrhythmias.
📌 The nurse must first check vital signs, especially apical pulse, because digoxin can cause bradycardia and hypotension.
📌 If the pulse is below 60 bpm, the nurse should withhold the drug and notify the provider immediately.
📌 Assessing vital signs promptly provides essential information to determine whether toxicity management (e.g., holding digoxin or administering digoxin immune Fab) is required.
📌 Monitoring and recognizing early signs of toxicity are crucial to preventing cardiac complications in heart failure clients.
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This question is from Custom: N303 Final 7/06 which contains 59 questions.
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Question Details
- Category: RN Nursing Exam(s)
- Subcategory: ATI Exam(s)
- Domain: RN Custom Exam(s)
- Answer Choices: 4