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 B
Explanation
Choice A rationale:
Ketorolac is a non-steroidal anti-inflammatory drug (NSAID) used for pain relief after surgery. However, it’s not typically administered every 3 hours. Overuse can lead to serious side effects.
Choice B rationale:
If the client’s pain level remains high after receiving ketorolac, administering an opioid medication like oxycodone may be appropriate.
Choice C rationale:
While acetaminophen can be used for pain relief, rectal administration is not typically the first choice for postoperative pain management.
Choice D rationale:
It’s inappropriate to label a patient as exhibiting drug-seeking behaviors simply because their reported pain level remains high after medication. Pain is subjective and should be addressed appropriately.
Correct Answer is B
Explanation
Choice A rationale:
While a tuberculin syringe can be used for insulin administration, it’s not necessary when mixing NPH and regular insulin. Insulin syringes are typically used for this purpose.
Choice B rationale:
Injecting air into each vial before withdrawing insulin helps equalize pressure and makes it easier to draw up the insulin. This should be done before withdrawing any insulin.
Choice C rationale:
Withdrawing NPH insulin first contradicts the standard practice of drawing up insulins. The usual recommendation is to draw up short-acting (regular) insulin before intermediate-acting (NPH) insulin.
Choice D rationale:
Shaking the regular insulin vial is unnecessary and could potentially create bubbles, making it harder to draw up the correct dose of insulin.
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