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 A
Explanation
Choice A rationale:
Sinus bradycardia with a heart rate of 48 is a potentially life-threatening condition that requires immediate assessment and intervention. The heart rate is significantly below the normal range of 60-100 beats per minute, which means that the heart is not pumping enough blood to meet the body's needs. This can lead to symptoms such as dizziness, lightheadedness, fatigue, shortness of breath, chest pain, and even syncope (fainting). In severe cases, it can progress to cardiac arrest and death.
The patient is awaiting pacemaker placement, indicating that the bradycardia is severe and not responding to other treatment measures. This further underscores the urgency of assessment and intervention.
The nurse needs to assess the patient immediately for signs of hemodynamic instability, such as hypotension, altered mental status, and decreased urine output. The nurse should also obtain a 12-lead ECG to confirm the diagnosis of sinus bradycardia and to rule out other potential causes of the bradycardia, such as AV block or medication effects.
Prompt intervention is crucial to prevent further deterioration of the patient's condition and to avoid potentially lifethreatening complications.
Choice B rationale:
Atrial fibrillation is a common heart rhythm disorder that is characterized by rapid and irregular beating of the heart's upper chambers (atria). It can cause symptoms such as palpitations, shortness of breath, fatigue, and lightheadedness.
Diltiazem is a calcium channel blocker that is often used to control the heart rate in patients with atrial fibrillation. While it is important to monitor patients who are newly started on diltiazem for potential side effects, such as hypotension and bradycardia, it is not as urgent as assessing a patient with severe sinus bradycardia.
Choice C rationale:
Thrombophlebitis is an inflammation of a vein that is often caused by a blood clot. It can cause pain, redness, swelling, and warmth in the affected area.
IV heparin is an anticoagulant medication that is used to prevent blood clots from forming or getting larger. While it is important to monitor patients who are receiving IV heparin for potential side effects, such as bleeding, it is not as urgent as assessing a patient with severe sinus bradycardia.
Choice D rationale:
End-stage, right-sided heart failure is a serious condition that is characterized by the inability of the heart to pump blood effectively from the right ventricle to the lungs. It can cause symptoms such as shortness of breath, fatigue, edema, and abdominal swelling.
Hospice care is a type of care that focuses on providing comfort and quality of life for patients who are nearing the end of life. While it is important to provide supportive care for patients who are on hospice care, it is not as urgent as assessing a patient with severe sinus bradycardia.
Correct Answer is ["A","C","D"]
Explanation
Choice A rationale:
Duration of pain: Stable angina typically lasts for less than 5 minutes, while pain from a myocardial infarction (MI) typically lasts longer, often 20 minutes or more. This is because stable angina is caused by a temporary decrease in blood flow to the heart muscle, while an MI is caused by a complete blockage of blood flow, leading to more severe and prolonged pain.
Mechanism of pain: The pain in stable angina is due to ischemia, which is a lack of oxygen to the heart muscle. This occurs when the demand for oxygen by the heart muscle exceeds the supply of oxygenated blood.
Nitrates and ischemia: Nitrates, such as nitroglycerin, work by dilating the coronary arteries, which increases blood flow to the heart muscle and relieves ischemia. This is why nitroglycerin is often effective in relieving the pain of stable angina.
Choice B rationale:
Non-specific symptom: Shortness of breath can occur with both stable angina and MI, as well as other conditions such as lung disease or anxiety. Therefore, it is not a specific symptom that can be used to differentiate between the two conditions.
Choice C rationale:
Activity level: Stable angina is typically triggered by exertion or emotional stress, which increase the heart's demand for oxygen.
Rest and angina: The pain often subsides with rest or nitroglycerin.
MI and rest: In contrast, the pain of an MI can occur at rest and is not always relieved by nitroglycerin.
Choice D rationale:
Nitrates and stable angina: As mentioned earlier, nitrates are often effective in relieving the pain of stable angina.
Nitrates and MI: However, they may not be as effective in relieving the pain of an MI, as the blockage of blood flow is more severe.
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