a client is receiving digoxin for heart failure what is the most important assessment for the nurse to perform before administering this medication
Logo

Nursing Elites

HESI RN

RN HESI Exit Exam Capstone

1. Before administering digoxin to a client with heart failure, what is the most important assessment for the nurse to perform?

Correct answer: B

Rationale: The correct answer is to monitor the client's heart rate. Digoxin slows the heart rate, so it is crucial to assess the heart rate before administering the medication. If the heart rate is below 60 beats per minute, the dose should be held, and the healthcare provider should be notified. Checking the blood pressure (Choice A) is important but not as crucial as monitoring the heart rate in this case. Assessing the respiratory rate (Choice C) is not directly related to the action of digoxin. Reviewing the client's potassium level (Choice D) is important for clients taking digoxin due to the risk of hypokalemia, but assessing the heart rate takes priority.

2. A client who had a vasectomy is in the post-recovery unit at an outpatient clinic. Which of these points is most important to be reinforced by the nurse?

Correct answer: A

Rationale: The most important point to reinforce after a vasectomy is to continue using contraception until the healthcare provider confirms the absence of sperm in the ejaculate. Choice A is correct because it emphasizes the necessity of another form of contraception until sperm absence is confirmed. Choice B is incorrect because it focuses on how a vasectomy works anatomically rather than the need for ongoing contraception. Choice C is incorrect as it discusses post-vasectomy care but does not address the need for continued contraception. Choice D is also incorrect as it refers to general post-procedure recommendations but does not highlight the crucial aspect of using contraception until sperm absence is confirmed.

3. The nurse is caring for a client with chronic heart failure who is receiving digoxin therapy. The nurse reviews the client's lab results and notes that the serum potassium level is 3.0 mEq/L. What action should the nurse take next?

Correct answer: C

Rationale: In clients receiving digoxin therapy, low potassium levels can increase the risk of digoxin toxicity. Therefore, when the nurse notes a serum potassium level of 3.0 mEq/L, it is crucial to hold the next dose of digoxin. Notifying the healthcare provider is essential to ensure appropriate interventions, such as potassium supplementation, can be implemented. Administering a potassium supplement without healthcare provider guidance may lead to rapid potassium level changes and potential adverse effects. Increasing dietary potassium intake alone may not promptly address the low serum potassium level in this acute situation.

4. A client with pheochromocytoma is admitted to the hospital. Which intervention has the highest priority?

Correct answer: B

Rationale: The correct answer is B: Start intravenous fluids at a fast rate. In a client with pheochromocytoma, the highest priority intervention is to ensure adequate intravascular volume before initiating any other treatment. This helps prevent a sudden drop in blood pressure that can occur due to the release of catecholamines during tumor manipulation. While monitoring blood pressure frequently is essential, ensuring adequate intravascular volume takes precedence. Administering pain medication and antihypertensive medications are important but are not the highest priority in the initial management of pheochromocytoma.

5. A client with hyperthyroidism is experiencing palpitations. What intervention should the nurse implement?

Correct answer: B

Rationale: In clients with hyperthyroidism experiencing palpitations, administering a beta-blocker is the appropriate intervention. Beta-blockers help reduce heart rate and control symptoms in hyperthyroidism. Encouraging rest (Choice A) may be helpful but does not directly address the palpitations. Drinking cool fluids (Choice C) and providing a cool environment (Choice D) are more focused on temperature regulation and comfort, which are not the primary interventions for palpitations in hyperthyroidism.

Similar Questions

What pathophysiological events occur sequentially in the development of atherosclerosis?
A client with hypoglycemia is unresponsive. What is the nurse's priority action?
A client is admitted to the hospital with a diagnosis of pneumonia. The client is prescribed intravenous antibiotics and oxygen therapy. Which assessment finding indicates that the client's condition is improving?
A client with psoriasis is prescribed topical corticosteroids. What side effect should the nurse monitor for?
After completing her first chemotherapy treatment, what behavior indicates that a female client with breast cancer understands her discharge care needs?

Access More Features

HESI RN Basic
$69.99/ 30 days

  • 5,000 Questions with answers
  • All HESI courses Coverage
  • 30 days access

HESI RN Premium
$149.99/ 90 days

  • 5,000 Questions with answers
  • All HESI courses Coverage
  • 30 days access

Other Courses