. A nurse is caring for a client who has congestive heart failure and is taking digoxin daily. The client

refusedbreakfastandiscomplainingofnauseaandweakness.Whichofthefollowingactionsshouldthenursetakefirst?

A. Check the client's vital signs.

Rationale: It is possible that the client's nausea is secondary to digoxin toxicity. By obtaining vital signs,

thenurse can assess for bradycardia, which is a symptom of digoxin toxicity. The nurse

shouldwithhold the medication and call the provider if the client's heart rate is less than 60 bpm.

B. Request a dietitian consult.

Rationale:Whilethe dietitian might be able to assist the client with making appropriate food choices, this

isnot the first action the nurse should take.

C. Suggest that the client rests before eating the meal.

Rationale:While this intervention mightbe appropriate, this is not the first action the nurse should take.

D. Request an order for an antiemetic.

Rationale:Whilethis intervention might relieve the client's nausea,this is not the first action the nurseshould

take.

2. A nurse is caring for a clientwho has thrombophlebitis and is receiving heparin by continuous IV

infusion.Theclient asks the nurse how long it will take for the heparin to dissolve the clot. Which of the following

responsesshould the nurse give?

A. "It usually takes heparin at least 2to 3 days to reach a therapeutic blood level."

Rationale: The effects of heparin begin within minutes. This response does not accurately answer

theclient's question.

B. "A pharmacist is the person to answer that question."

Rationale:Contacting the pharmacist is not the appropriate answer for the nurse to give.

C. "Heparin does not dissolve clots. It stops new clots from forming."

Rationale: Thisstatementaccuratelyanswerstheclient'squestion.

D. "The oral medication you will take after this IV will dissolve the clot."

Rationale: This is not a correct response. Warfarin,a PO medication that is often started after the

clienthas been on heparin, does not dissolve clots.