Exam 2 practice ATI Detailed Answer Key

1. A nurse is caring for a client who has congestive heart failure and is taking digoxin daily. The client refused breakfast and is complaining of nausea and weakness. Which of the following actions should the nurse take first? A. Check the client's vital signs. Rationale: It is possible that the client's nausea is secondary to digoxin toxicity. By obtaining vital signs, the nurse can assess for bradycardia, which is a symptom of digoxin toxicity. The nurse should withhold the medication and call the provider if the client's heart rate is less than 60 bpm. B. Request a dietitian consult. Rationale: While the dietitian might be able to assist the client with making appropriate food choices, this is not the first action the nurse should take. C. Suggest that the client rests before eating the meal. Rationale: While this intervention might be appropriate, this is not the first action the nurse should take. D. Request an order for an antiemetic. Rationale: While this intervention might relieve the client's nausea, this is not the first action the nurse should take. 2. A nurse is caring for a client who has thrombophlebitis and is receiving heparin by continuous IV infusion. The client asks the nurse how long it will take for the heparin to dissolve the clot. Which of the following responses should the nurse give? A.