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    PN Comprehensive Predictor 2023 Proctored Exam

    A nurse is preparing to administer a dose of digoxin to a client who is experiencing heart failure. Which of the following actions should the nurse take prior to administering this medication?

    Explanation & Rationale

    A. Auscultate the client's lung sounds: While assessing lung sounds is an important part of the overall assessment for a client with heart failure (to check for pulmonary edema/crackles), it is not a specific requirement for the administration of digoxin. It helps evaluate the effectiveness of the treatment over time but does not determine if the current dose is safe to give. B. Check the client's weight: Daily weights are essential for monitoring fluid volume status in heart failure patients. However, like lung sounds, this is an assessment of the disease progression rather than a safety check for the medication's immediate effect on the heart's electrical system. C. Check the client's apical pulse: Digoxin can cause bradycardia and other arrhythmias. The nurse must assess the apical pulse for a full minute before administration and withhold the medication if the rate is below the provider’s prescribed parameters (commonly <60 bpm in adults). D. Obtain the client's oxygen saturation: Oxygen saturation provides information about respiratory status but does not directly influence the decision to administer digoxin.

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