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:
It is inaccurate to state that men exclusively present with atypical symptoms of CAD. While men are more likely than women to experience atypical symptoms, this does not mean that they never experience chest pain or other typical symptoms.
Chest pain remains the most common symptom of CAD in both men and women. However, it's important to recognize that both genders can experience a range of symptoms, including atypical ones.
Attributing atypical symptoms solely to men can lead to misdiagnosis or delayed diagnosis of CAD in women. This is because women are more likely to present with atypical symptoms, and healthcare professionals may not recognize these symptoms as indicative of CAD.
It's crucial to consider a broad spectrum of symptoms when evaluating patients for potential CAD, regardless of gender.
Choice B rationale:
Chest pain is indeed the most common symptom of CAD. It typically manifests as a feeling of pressure, squeezing, or tightness in the chest, often radiating to the left arm, jaw, neck, or back.
Chest pain usually occurs during exertion or emotional stress and is relieved by rest or nitroglycerin.
Choice C rationale:
Atherosclerosis is the most common underlying cause of CAD. It's a condition characterized by the buildup of plaque within the arteries, leading to narrowing and hardening of the vessels.
This plaque buildup can restrict blood flow to the heart muscle, resulting in ischemia (lack of oxygen) and the symptoms of CAD.
Choice D rationale:
Elevated LDL cholesterol is a significant risk factor for developing CAD. LDL cholesterol is often referred to as "bad" cholesterol because it can contribute to plaque buildup in the arteries.
Managing LDL cholesterol levels through lifestyle modifications and medications, if necessary, is crucial for reducing the risk of CAD.
Correct Answer is D
Explanation
Choice A rationale:
While bananas do contain fiber, which is beneficial for digestive health and can help regulate blood sugar levels, it is not the most relevant information for a patient with electrolyte imbalance induced ventricular tachycardia. The primary focus should be on addressing the electrolyte imbalance, specifically potassium levels.
Choice B rationale:
Bananas do contain manganese, an essential mineral that plays a role in bone health, metabolism, and wound healing. However, manganese is not directly involved in regulating electrolytes or heart rhythm. Therefore, it's not the most pertinent information for this patient's condition.
Choice C rationale:
While it's true that bananas are relatively low in sodium, this information is not as crucial for a patient with electrolyte imbalance induced ventricular tachycardia. Potassium, not sodium, is the electrolyte that's most likely to be deficient in this condition and needs to be addressed.
Choice D rationale:
Bananas are an excellent source of potassium, a crucial electrolyte that plays a vital role in regulating heart rhythm, muscle contractions, and nerve function. Potassium deficiency, or hypokalemia, can lead to various cardiac arrhythmias, including ventricular tachycardia. Therefore, increasing potassium intake through dietary sources like bananas can be an effective strategy to help manage electrolyte imbalance and potentially reduce the risk of arrhythmias.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today