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 C
Explanation
A) Check the weight of the patient:
While weight monitoring is important in managing heart failure and tracking fluid retention, it is not the most critical action before administering digoxin. Digoxin primarily affects heart rate and rhythm, so the priority assessment is related to the cardiovascular system.
B) Check the skin for bruising:
Checking for bruising is not a necessary step before administering digoxin. Bruising could be an indication of an underlying bleeding disorder or anticoagulant therapy, but it is not directly related to the administration of digoxin. The primary concern with digoxin is its effect on the heart, particularly heart rate and rhythm.
C) Check the apical pulse:
It is crucial to check the apical pulse before administering digoxin, as one of the major effects of the drug is to slow the heart rate (negative chronotropy). If the heart rate is below 60 beats per minute (bpm), the nurse should hold the medication and consult the healthcare provider, as digoxin can further decrease the heart rate and lead to bradycardia or other complications.
D) Check the temperature of the patient:
Although monitoring vital signs, including temperature, is important in overall patient care, temperature does not specifically impact the administration of digoxin. A normal or abnormal temperature would not typically influence the decision to give digoxin unless the patient had a fever due to an underlying infection that could complicate the clinical picture. The priority is assessing the pulse to ensure safe administration of the medication.
Correct Answer is D
Explanation
Given:
Volume of fluid: 50 mL (DSW) + 10 mL (for reconstitution) = 60 mL
Infusion time: 45 minutes
Drop factor: 10 gtt/mL
Formula:
Flow rate (gtt/min) = (Volume (mL) / Time (min)) x Drop factor (gtt/mL)
Step 1: Calculate the infusion rate in mL/min:
Infusion rate (mL/min) = Volume (mL) / Time (min)
Infusion rate (mL/min) = 60 mL / 45 min
Infusion rate (mL/min) = 1.33 mL/min
Step 2: Calculate the flow rate in gtt/min:
Flow rate (gtt/min) = Infusion rate (mL/min) x Drop factor (gtt/mL)
Flow rate (gtt/min) = 1.33 mL/min x 10 gtt/mL
Flow rate (gtt/min) = 13.3 gtt/min
Step 3: Round to the nearest whole number:
Flow rate (gtt/min) ≈ 13 gtt/min
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