for the week of 03.06.06
A client has had heart failure. Which intervention is most important for the nurse to implement prior to the initial admininstration of digoxin to this client?
1. Assess the apical pulse, counting for a full 60 seconds
2. Take a radial pulse, counting for a full 60 seconds
3. Use the pulse reading from the electronic blood pressure device
4. Check for a pulse deficit
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Answer
The correct answer is number: 1
It is the nurse’s responsibility to take the client’s pulse before administering digoxin. The correct technique for taking an apical pulse is to use the stethoscope and listen for a full 60 seconds. Digoxin is held for a pulse below 60 beats per minute. A radial pulse, potentially less accurate, or blood pressure are not part of the initial assessment before administering an initial dose of digoxin.
Smeltzer, S.C., & Bare, B.G. (2004)
Medical surgical nursing
Philadelphia, PA. Lippincott Williams & Wilkins.
Altman, G. (2004)
Delmar’s fundamental and advanced nursing skills (2nd ed.)
Albany, NY: Delmar.
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