The client is receiving digoxin and has a potassium level of 2.8 mEq/L. What is the nurse's priority action?

Correct Answer: A

Rationale: The correct answer is A: Hold the digoxin and notify the healthcare provider. Digoxin toxicity is more likely to occur in patients with low potassium levels. With a potassium level of 2.8 mEq/L, the client is at risk for digoxin toxicity. Holding the digoxin and notifying the healthcare provider is the priority action to prevent potential harm to the client. B: Increasing the dose of digoxin would exacerbate the risk of digoxin toxicity in a client with low potassium levels. C: Continuing the current dose of digoxin without addressing the low potassium level could lead to digoxin toxicity. D: Administering potassium supplements alone may not be sufficient to address the potential digoxin toxicity. Holding the digoxin is the priority action.

Correct Answer: A

Rationale: The correct answer is A: Platelet count. When administering enoxaparin, the most important lab value to monitor is the platelet count because enoxaparin can cause thrombocytopenia, a potentially serious adverse effect. Monitoring platelet count helps to detect and prevent this complication. Summary of other choices: B: aPTT - Enoxaparin does not directly affect aPTT, so monitoring this value is not as critical as platelet count. C: Hemoglobin - While monitoring hemoglobin may be important for some conditions, it is not the most crucial lab value to monitor when administering enoxaparin. D: INR - Enoxaparin does not affect the INR, so monitoring this value is not necessary when administering this medication.

Correct Answer: A

Rationale: The correct answer is A: Platelet count. When administering enoxaparin for DVT prophylaxis, monitoring platelet count is crucial because enoxaparin can cause thrombocytopenia. Decreased platelet count can increase the risk of bleeding. Monitoring PT/INR and aPTT is more relevant for monitoring warfarin or heparin therapy, not enoxaparin. Hemoglobin monitoring is important for assessing anemia but not specifically related to enoxaparin administration for DVT prophylaxis.

Correct Answer: A

Rationale: The correct answer is A: Hold the spironolactone and notify the healthcare provider. Spironolactone is a potassium-sparing diuretic that can lead to hyperkalemia. With a potassium level of 6.0 mEq/L, the client is at risk for serious cardiac complications. Holding the medication and notifying the healthcare provider is the priority to prevent further increase in potassium levels. Administering a potassium supplement (B) would exacerbate the hyperkalemia. Continuing the spironolactone as ordered (C) or increasing the dose (D) would also worsen the situation.

Correct Answer: A

Rationale: The correct answer is A: Hold the beta blocker and notify the healthcare provider. A blood pressure of 88/58 mm Hg is considered hypotension, which can be a serious side effect of beta blockers. By holding the medication and notifying the healthcare provider, the nurse ensures prompt assessment and appropriate intervention. Administering the beta blocker (B) could further lower the blood pressure. Increasing the dose (C) would exacerbate the hypotension. Continuing to monitor and reassess (D) is not sufficient as immediate action is required due to the low blood pressure reading.