A patient is ordered to receive digoxin to treat congestive heart failure. The nurse is most concerned about which assessment finding.
RR 18 bpm
1+ pitting edema of the lower extremities
BP 138/90 mm Hg
Heart rate 54 beats/min
The Correct Answer is D
A) RR 18 bpm:
A respiratory rate of 18 breaths per minute is within the normal range for adults (12-20 bpm). Therefore, this finding does not pose a significant concern in the context of digoxin therapy. Respiratory rate should be monitored, especially if the patient is experiencing signs of heart failure or digoxin toxicity, but 18 bpm alone is not alarming.
B) 1+ pitting edema of the lower extremities:
Pitting edema, especially with a grade of 1+ (slight indentation), is a common finding in patients with congestive heart failure (CHF). It indicates fluid retention due to the heart's inability to pump blood effectively. While edema should be monitored, it is not immediately life-threatening or specific to digoxin toxicity.
C) BP 138/90 mm Hg:
A blood pressure of 138/90 mm Hg is slightly elevated, but it is not excessively high. This finding is manageable and should be monitored, particularly in heart failure patients, but it does not present an immediate concern in this case. Blood pressure management is crucial in CHF, but it does not directly correlate with digoxin toxicity.
D) Heart rate 54 beats/min:
A heart rate of 54 beats per minute is considered bradycardic, especially in a patient taking digoxin. Digoxin can lower heart rate by increasing vagal tone and inhibiting the AV node. Bradycardia is a well-known sign of digoxin toxicity, and this finding is concerning because it may indicate that the patient is experiencing toxicity. Digoxin-induced bradycardia can lead to more serious arrhythmias or hemodynamic instability, making this the most concerning finding that requires immediate assessment and possibly intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Let’s break this down step by step:
Key information:
Formula available: Glucerna 1.2 calories, 237 mL can
Order: Tube feeding at ½ strength (means equal parts formula + water)
Rate: 65 mL/hr
Calculation:
To make ½ strength, you must dilute the formula with an equal volume of water.
Available formula = 237 mL
Therefore, water needed = 237 mL
Correct Answer: A. 237 mL
Correct Answer is C
Explanation
A) High protein diet:
While a healthy diet is essential for managing heart disease, a high-protein diet is not specifically recommended as a nonpharmacologic control for heart disease. A balanced diet that includes adequate protein, healthy fats, and low saturated fats, while being high in fruits, vegetables, and whole grains, is more beneficial for heart health.
B) Decrease exercise:
Decreasing exercise is not recommended for heart disease management. In fact, regular physical activity is a key aspect of preventing and managing heart disease. Moderate exercise, such as walking, swimming, or cycling, helps improve cardiovascular health by lowering blood pressure, improving cholesterol levels, and reducing stress.
C) Smoking cessation:
Smoking cessation is one of the most important nonpharmacologic strategies for managing heart disease. Smoking is a major risk factor for heart disease because it damages the blood vessels, increases blood pressure, and promotes the formation of blood clots. Quitting smoking can significantly reduce the risk of heart disease, improve circulation, and lower the risk of heart attack and stroke.
D) Increase water intake:
While staying hydrated is important for overall health, there is no specific evidence to suggest that increasing water intake directly controls heart disease. However, maintaining proper hydration supports kidney function and circulatory health, and can assist with managing blood pressure.
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