Before administering digoxin to a client with valvular disease, the nurse assesses the apical heart rate as 62 beats/minute. The client's usual rate ranges between 66 to 72 beats/minute. Which is the best action for the nurse to take?

Notify the physician.

Recheck the apical pulse in 30 minutes.

Administer the digoxin.

Hold the digoxin.

Answer and Explanation

The Correct Answer is C

A. Notify the physician: There is no immediate need to notify the provider since the heart rate is above the standard threshold for withholding digoxin. Clinical parameters are still within safe limits for administration.
B. Recheck the apical pulse in 30 minutes: Rechecking later may delay necessary therapy without cause. The heart rate is currently adequate, and there is no indication of bradycardia or instability.
C. Administer the digoxin: Digoxin is generally held if the apical heart rate is below 60 beats/minute in adults. Since the pulse is 62 and the client’s baseline is slightly higher, it is safe to administer the medication while continuing to monitor for any signs of bradycardia.
D. Hold the digoxin: Holding the dose is unnecessary unless the heart rate falls below 60 or there are signs of toxicity. In this case, the current rate does not warrant withholding the drug.

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Correct Answer is B

Explanation

A. Limited gas exchange: Impaired gas exchange occurs in earlier stages of shock due to poor perfusion and fluid accumulation, especially in the lungs. While serious, it is typically one component and not the final pathway leading to death.
B. Multiple organ failure: Irreversible shock leads to widespread cellular death and systemic hypoperfusion, causing failure of multiple organ systems. Once multiple organs shut down, the body can no longer sustain life due to failure of the body's compensatory mechanisms, and recovery is no longer possible.
C. Endotoxins in the system: Endotoxins may be present in septic shock and can contribute to inflammation and organ damage. However, their presence alone does not define the terminal stage of shock without resulting in systemic organ failure.
D. Brain death: Brain death may result from prolonged hypoxia or trauma, but it is not the defining feature of irreversible shock. In this stage, death results from the collapse of multiple organ systems rather than isolated neurological failure.

A. Maintain activity restriction to bedrest. B. Limit interaction with visitors. C. Avoid heavy meals. D. Arrange personal care supplies nearby.

Correct Answer is A

Explanation

A. Maintain activity restriction to bedrest: Bedrest reduces the heart's workload by minimizing physical exertion, thereby decreasing myocardial oxygen demand. This is crucial in cardiogenic shock, where the heart's pumping ability is severely compromised.
B. Limit interaction with visitors: While excessive stimulation can be stressful, limiting social interaction has a minimal impact on myocardial oxygen consumption compared to physical activity. Emotional support from visitors can actually benefit the client’s overall well-being.
C. Avoid heavy meals: Heavy meals may cause postprandial increases in metabolic demand, but they are not as directly impactful on cardiac workload as restricting physical activity. Meal composition should still be considered, but it's not the most immediate priority.
D. Arrange personal care supplies nearby: Placing supplies within reach helps minimize exertion during ADLs, but this is a supportive measure. Complete activity restriction is a more direct and effective intervention to reduce cardiac oxygen demand in the acute phase.

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Before administering digoxin to a client with valvular disease, the nurse assesses the apical heart rate as 62 beats/minute. The client's usual rate ranges between 66 to 72 beats/minute. Which is the best action for the nurse to take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a client in the irreversible stage of shock. The nurse is explaining to the client's family the poor prognosis. Which would the nurse be most accurate to explain as the rationale for imminent death?

Correct Answer is B

Explanation

The nurse is planning care for a client diagnosed with cardiogenic shock. Which nursing intervention is most helpful to decrease myocardial oxygen consumption?

Correct Answer is A

Explanation

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