Difficulty: Medium
Average Score: 95%
Simulated
A nurse is reviewing a client's medication administration record and finds digoxin was administered to the client with a heart rate of 58/min. Which of the following actions should the nurse take first?
Correct answer
D
Rationale
The correct answer is D: Examine the client's vital signs and condition first. This is the priority as digoxin can cause bradycardia, and a heart rate of 58/min is below the normal range. The nurse must assess the client's current condition for signs of digoxin toxicity, such as nausea, vomiting, or visual disturbances. This immediate assessment will help determine the client's need for further interventions or medical attention.
Other choices are incorrect:
A: Notifying the nurse manager can be done later after ensuring the client's safety.
B: Filing an incident report is important but should not be the immediate action.
C: Notifying the provider is necessary but assessing the client's condition is the priority.
In summary, examining the client first ensures immediate intervention for potential digoxin toxicity, while the other options can be addressed subsequently.
Other choices are incorrect:
A: Notifying the nurse manager can be done later after ensuring the client's safety.
B: Filing an incident report is important but should not be the immediate action.
C: Notifying the provider is necessary but assessing the client's condition is the priority.
In summary, examining the client first ensures immediate intervention for potential digoxin toxicity, while the other options can be addressed subsequently.