A nurse is preparing to administer digoxin to a client.
For which of the following findings should the nurse withhold the medication?
Apical pulse 54/min.
Respiratory rate 14/min.
BP 179/89 mm Hg.
Temperature 37.8° C (100° F)
The Correct Answer is A
Choice A rationale:
An apical pulse of 54/min is below the normal range for adults. Digoxin, a cardiac medication, can lower the heart rate. Therefore, it’s crucial to hold the medication if the resting pulse for an adult is less than 60 bpm. This is to prevent further lowering of the heart rate which could lead to bradycardia, a potentially dangerous condition.
Choice B rationale:
A respiratory rate of 14/min is within the normal adult range of 12-20 breaths per minute. This would not be a reason to withhold digoxin.
Choice C rationale:
A blood pressure (BP) of 179/89 mm Hg indicates hypertension, which is not a direct contraindication for digoxin. However, it’s important to monitor BP levels in clients taking digoxin as the medication can affect blood pressure.
Choice D rationale:
A temperature of 37.8° C (100° F) is slightly elevated but would not be a reason to withhold digoxin unless it’s indicative of an underlying infection that needs to be addressed first.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Correct Answer is C
Explanation
Choice A rationale:
Increased temperature is not a direct indication of naloxone’s effectiveness. Naloxone works by reversing the effects of opioids, which do not typically include fever.
Choice B rationale:
While naloxone can cause an abrupt withdrawal in opioid-dependent individuals, leading to symptoms such as hypertension, it does not typically decrease blood pressure in opioid overdose cases.
Choice C rationale:
Naloxone works by reversing the life-threatening depression of the central nervous system and respiratory system caused by an opioid overdose. Therefore, an increased respiratory rate after administration would indicate that the medication is effective.
Choice D rationale:
Naloxone reverses the effects of opioids, including pain relief. Therefore, a report of decreased pain would not indicate that the medication is effective.
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