A nurse is administering digoxin to a patient.
What priority assessment needs to take place prior to administration?
Assess lung sounds prior to administration
Assess systolic blood pressure 10 minutes prior to administration
Assess brachial pulse for 30 seconds
Assess apical pulse for 60 seconds
The Correct Answer is D
Choice A rationale:
Assessing lung sounds is important for evaluating respiratory status, but it is not the priority assessment before administering digoxin. Digoxin does not have a direct effect on the respiratory system, and changes in lung sounds would not necessarily indicate a contraindication to its administration.
However, in patients with heart failure, which is a common indication for digoxin, auscultating lung sounds can provide valuable information about fluid status and the effectiveness of treatment. Therefore, while not the priority assessment, lung auscultation remains a relevant part of the overall assessment of a patient receiving digoxin.
Choice B rationale:
Assessing systolic blood pressure is important for monitoring hemodynamic status, but it is not the most critical assessment before administering digoxin. Digoxin does not directly affect blood pressure, and changes in blood pressure would not necessarily indicate a contraindication to its administration.
However, in patients with hypertension, which can be a factor in heart failure, monitoring blood pressure is essential for managing overall cardiovascular health. Therefore, while not the priority assessment, blood pressure measurement remains an important aspect of care for patients receiving digoxin.
Choice C rationale:
Assessing the brachial pulse for 30 seconds can provide a general assessment of heart rate and rhythm, but it is not as accurate as assessing the apical pulse for a full minute.
The apical pulse is the most reliable way to assess heart rate and rhythm, especially in patients with irregular heartbeats or those taking medications that can affect heart rate, such as digoxin.
Therefore, assessing the apical pulse for a full minute is essential to ensure accurate assessment of the patient's cardiac status before administering digoxin.
Choice D rationale:
Assessing the apical pulse for 60 seconds is the priority assessment before administering digoxin. This is because digoxin is a cardiac glycoside that affects the heart's electrical conduction system and can slow the heart rate. It is essential to assess the patient's heart rate and rhythm before administering digoxin to ensure that it is safe to do so.
A slow heart rate (bradycardia), irregular heart rhythms (such as atrial fibrillation), or certain heart block conditions can be contraindications to digoxin administration or require dosage adjustments.
By accurately assessing the apical pulse for a full minute, the nurse can identify any potential contraindications or concerns and ensure the safe administration of digoxin.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
While an ICD can sometimes be used to treat bradycardia (an abnormally slow heart rate), this is not its primary function.
Pacemakers are more commonly used to manage bradycardia.
They work by continuously monitoring the heart's rhythm and delivering electrical impulses to the heart muscle when needed to maintain a normal heart rate.
Choice B rationale:
Atrial fibrillation (AFib) is a type of arrhythmia that causes the upper chambers of the heart (atria) to beat irregularly and rapidly.
ICDs are not typically used to treat AFib.
Instead, medications such as beta-blockers or calcium channel blockers are often used to control the heart rate and rhythm in patients with AFib. In some cases, a procedure called ablation may be used to destroy the areas of the heart that are causing the abnormal electrical signals.
Choice C rationale:
The primary purpose of an ICD is to detect and treat ventricular arrhythmias, which are potentially life-threatening rhythm disturbances that originate in the lower chambers of the heart (ventricles).
Ventricular fibrillation (VF) is a chaotic, rapid rhythm that prevents the heart from pumping blood effectively.
Ventricular tachycardia (VT) is a very fast heart rhythm that can also lead to cardiac arrest.
ICDs can deliver electrical shocks to the heart to restore a normal rhythm when these dangerous arrhythmias occur.
This can prevent sudden cardiac death (SCD).
Choice D rationale:
While an ICD can deliver a shock to the heart in the event of a heart attack, this is not its primary purpose.
It's important to note that an ICD cannot prevent a heart attack from happening; it can only treat the life-threatening arrhythmias that may result from a heart attack.
Correct Answer is C
Explanation
Answer and explanation
The correct answer is C. Normal Sinus Rhythm.
Choice A rationale:
Asystole is the absence of all electrical activity in the heart, as evidenced by a flat line on the electrocardiogram (ECG). It is a medical emergency that requires immediate cardiopulmonary resuscitation (CPR) and defibrillation.
Key features of asystole on ECG:
No discernible P waves, QRS complexes, or T waves.
A completely flat or nearly flat line on the ECG tracing.
Choice B rationale:
Atrial flutter is a rapid heart rhythm that arises from abnormal electrical activity in the atria. It is characterized by a sawtooth pattern on the ECG, with atrial rates typically between 250 and 350 beats per minute.
Key features of atrial flutter on ECG:
Absence of distinct P waves, instead replaced by flutter waves (sawtooth pattern).
Regular, rapid atrial rate (typically 250-350 bpm).
QRS complexes may be normal or slightly irregular in appearance.
Choice C rationale:
Normal sinus rhythm is the natural, healthy rhythm of the heart. It originates in the sinoatrial (SA) node, the heart's natural pacemaker, and is characterized by a regular rate of 60-100 beats per minute, with consistent P waves, QRS complexes, and T waves on the ECG.
Key features of normal sinus rhythm on ECG:
Presence of distinct P waves, QRS complexes, and T waves.
Regular rhythm with a rate of 60-100 beats per minute.
PR interval (the time between the P wave and QRS complex) is 0.12-0.20 seconds.
QRS duration (the time it takes for the ventricles to depolarize) is less than 0.12 seconds.
Choice D rationale:
Sinus bradycardia is a slow heart rhythm, with a rate below 60 beats per minute. It is often a normal finding in healthy individuals, especially athletes or during sleep. However, it can also be a sign of underlying medical conditions.
Key features of sinus bradycardia on ECG:
Presence of distinct P waves, QRS complexes, and T waves.
Regular rhythm with a rate less than 60 beats per minute.
PR interval and QRS duration are typically normal.
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