A client with congestive heart failure taking digoxin refused breakfast and is complaining of nausea and weakness. Which action should the nurse take first?

Correct Answer: A

Rationale: In this scenario, the correct action for the nurse to take first is to check the client's vital signs (Option A). This is crucial because the client is experiencing symptoms of nausea and weakness, which could be indicative of digoxin toxicity. Digoxin, a medication commonly used in heart failure, has a narrow therapeutic range, and symptoms of toxicity include gastrointestinal disturbances like nausea and weakness. By checking the vital signs, the nurse can assess for signs of digoxin toxicity such as bradycardia or arrhythmias, which would require immediate intervention. Requesting a dietitian consult (Option B) is not the priority in this situation as the client's symptoms are more acute and require immediate assessment. Suggesting that the client rests before eating (Option C) may not address the underlying issue of digoxin toxicity, and delaying necessary interventions can be harmful. Requesting an order for an antiemetic (Option D) may help alleviate the client's symptoms temporarily but does not address the potential toxicity of digoxin. This scenario highlights the importance of prompt assessment and prioritization of interventions in clients taking medications with a narrow therapeutic index like digoxin. Nurses must be vigilant in recognizing and managing medication side effects to ensure patient safety and well-being.

Correct Answer: D

Rationale: Rationale: The correct answer is D) You should report any tendon discomfort you experience while taking this medication. Ciprofloxacin belongs to a class of antibiotics known as fluoroquinolones, which have been associated with tendonitis and tendon rupture as potential adverse effects. It is crucial for the nurse to instruct the client to report any tendon discomfort promptly to prevent serious complications. Option A) If the medication causes an upset stomach, take an antacid at the same time is incorrect because ciprofloxacin should not be taken with antacids containing aluminum, calcium, or magnesium as they can interfere with the absorption of the antibiotic. Option B) Increase your daily fluid intake while taking this medication is incorrect but still important advice for UTI treatment to help flush out the bacteria. However, it is not specific to ciprofloxacin therapy. Option C) This medication can cause photophobia, so avoid direct sunlight exposure is incorrect. While photosensitivity can be a side effect of some medications, it is not a common side effect of ciprofloxacin. In an educational context, this question highlights the importance of understanding the potential side effects and monitoring parameters of specific medications, emphasizing the need for accurate patient education to ensure safe and effective treatment outcomes in pharmacology practice.

Correct Answer: A

Rationale: The therapeutic effect of lisinopril, an ACE inhibitor, is indicated by a decrease in blood pressure. Lisinopril works by relaxing blood vessels, leading to a reduction in blood pressure. Monitoring and achieving a decrease in blood pressure is a key outcome when managing hypertension with lisinopril.

Correct Answer: B

Rationale: The client stating that they have been taking an antacid to help with indigestion while on naproxen requires further discussion as it can indicate gastrointestinal distress or potential interactions between the medications. Antacids may affect the absorption of naproxen or lead to other complications, so it is important for the nurse to address this statement with the client.

Correct Answer: C

Rationale: Muscle pain should be reported immediately as it can indicate rhabdomyolysis, a severe adverse effect of atorvastatin. Rhabdomyolysis is characterized by muscle pain, weakness, and can lead to serious complications such as kidney damage, making it crucial for the nurse to notify the provider promptly.