A nurse is caring for a 6 year old client who has congestive heart failure and is taking digoxin daily. The client refused breakfast and is complaining of nausea a a and weakness. W Which of the following actions should the nurse take first?

Rationale: A. Request a dietitian consult is incorrect because dietary modifications may be important for a child with congestive heart failure, but this is not the immediate priority when the client is showing potential signs of digoxin toxicity. B. Check the client's vital signs is correct because nausea, vomiting, and weakness in a child taking digoxin can indicate digoxin toxicity, which can affect heart rate and rhythm. The nurse should first assess vital signs, particularly the heart rate, as digoxin toxicity can cause bradycardia or other dysrhythmias, which may be life-threatening. Assessment is always the first step according to the nursing process and the principle of safety first. C. Request an order for an antiemetic is incorrect because treating symptoms without assessing the client could mask a potentially serious medication-related complication. Administering an antiemetic would not address the underlying risk of toxicity. D. Suggest that the client rests before eating the meal is incorrect because resting does not address the potential danger of digoxin toxicity. Weakness and nausea may indicate cardiac compromise, so immediate assessment is necessary before implementing comfort measures.