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)

Answer and Explanation

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.

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Correct Answer is C

Explanation

Choice A rationale:

Dry mouth is a common side effect of diphenhydramine. Diphenhydramine is an antihistamine that is often used to treat allergies, insomnia, and symptoms of the common cold. It works by blocking the effects of histamine, a substance in the body that causes allergy symptoms. One of the effects of histamine is increased salivation, so when diphenhydramine blocks this effect, it can lead to dry mouth.

Choice B rationale:

Nausea is also a common side effect of diphenhydramine. This can occur because diphenhydramine can slow down the emptying of the stomach, leading to feelings of nausea. Additionally, diphenhydramine can affect the vestibular system in the inner ear, which can also lead to feelings of nausea.

Choice C rationale:

Agitation is considered an idiosyncratic reaction to diphenhydramine. An idiosyncratic reaction is an unusual or unexpected reaction to a drug that is not related to the usual pharmacological action of the drug. While diphenhydramine is typically used for its sedative effects, in some cases it can cause paradoxical central nervous system stimulation, leading to agitation.

Choice D rationale:

Dizziness is another common side effect of diphenhydramine. This occurs because diphenhydramine can affect the vestibular system in the inner ear, which plays a key role in maintaining balance. When this system is affected, it can lead to feelings of dizziness.

A. Spread the ointment in a 10 cm² (4 in) area. B. Massage the ointment into the skin. C. Apply the ointment in a thick layer. D. Cover the administration area with plastic wrap.

Correct Answer is D

Explanation

Choice A rationale:

Spreading the ointment in a 10 cm² (4 in) area is not the recommended method for nitroglycerin ointment application. The ointment should be applied over a 6x inch area in a thin, uniform layer.

Choice B rationale:

Massaging the ointment into the skin is not advised. The ointment should be applied in a thin layer and left to absorb into the skin.

Choice C rationale:

Applying the ointment in a thick layer is not recommended. A thin, uniform layer is sufficient for therapeutic effect.

Choice D rationale:

Covering the administration area with plastic wrap is the correct action. This helps to keep the ointment in place and enhances absorption.

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A nurse is preparing to administer digoxin to a client.For which of the following findings should the nurse withhold the medication?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is collecting data from a client who received diphenhydramine for insomnia. Which of the following findings should the nurse identify as an idiosyncratic reaction?

Correct Answer is C

Explanation

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Correct Answer is D

Explanation

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A nurse is preparing to administer digoxin to a client.
For which of the following findings should the nurse withhold the medication?