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br>History and Physical

BP 100/60 mm Hg Pulse 52/min
Respiratory rate 20/min

Temperature 37.2" C (99.0° F)

A nurse is caring for an adolescent who is receiving treatment for heart failure. Based on the

client's chart findings, which of the following actions should the nurse plan to take? (Click on the "Exhibit" button for additional information about the client. There are three tabs that contain separate categories of data.)

A.

Administer furosemide.

B.

Withhold digoxin.

C.

Withhold spironolactone.

D.

Administer ferrous sulfate.

Answer and Explanation

The Correct Answer is B

A. Administering furosemide may also be appropriate for managing heart failure symptoms, but the priority action based on the client's condition is to withhold digoxin.

B. The client's vital signs indicate bradycardia (pulse 52/min), which is a common adverse effect of digoxin, especially in the setting of heart failure. Withholding digoxin is necessary to prevent further exacerbation of bradycardia and potential toxicity.

C. Withholding spironolactone may be considered if there are concerns about electrolyte imbalances, but it is not the priority action in this scenario.

D. Administering ferrous sulfate is not indicated based on the client's chart findings; there is no indication of anemia or iron deficiency.


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Related Questions

Correct Answer is A

Explanation

A.

A. It's important to include the complete name of the medication to ensure clarity and accuracy in documentation.

B. Omitting the leading zero before a decimal point can lead to medication errors, so it's important to include it.

C. "U" is commonly used to denote units when documenting insulin dosage, so this statement is accurate.

D. "QOD" is an outdated abbreviation and can lead to confusion, so it should not be used; instead, "every other day" should be written out for clarity.

Correct Answer is ["92"]

Explanation

  • Pulse pressure is the difference between systolic and diastolic blood pressure.
  • The client's pulse pressure is 132 - 40 = 92 mm Hg.

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