Prior to giving digoxin the practical nurse (PN) assesses that a 2-month-old infant's heart rate is 120 beats/minute. Based on this finding, which action should the PN take?
Hold the medication and recheck the heart rate in 1 hour.
Administer the medication and document the heart rate.
Administer the medication and alert the charge nurse.
Hold the medication and document cardiac assessment.
The Correct Answer is B
A. Hold the medication and recheck the heart rate in 1 hour: Withholding digoxin is indicated if the infant’s heart rate is below the recommended threshold (usually <90–110 bpm for infants). A heart rate of 120 bpm is above this limit, so holding the dose is unnecessary.
B. Administer the medication and document the heart rate: A heart rate of 120 bpm is within the safe range for a 2-month-old infant. Administering digoxin and documenting the cardiac assessment is appropriate, ensuring ongoing monitoring for therapeutic effect and potential toxicity.
C. Administer the medication and alert the charge nurse: Since the heart rate is within normal limits, notifying the charge nurse is not required. Routine documentation and monitoring are sufficient.
D. Hold the medication and document cardiac assessment: Holding digoxin when the heart rate is appropriate may compromise therapeutic management of heart failure. Documentation alone is insufficient without administering the prescribed dose.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Mental status: Assessing mental status is essential before administering zolpidem because it is a sedative-hypnotic medication. Evaluating orientation, alertness, and cognitive function helps ensure the client can safely take the medication and reduces the risk of falls, confusion, or respiratory depression.
B. Skin integrity: While skin assessment is important for overall care, it is not directly related to the administration or safety of zolpidem. Skin integrity does not influence the drug’s sedative effects.
C. Body temperature: Monitoring body temperature is not necessary prior to zolpidem administration. Fever or hypothermia does not typically affect the immediate safety or effectiveness of the medication.
D. Bowel sounds: Assessing bowel sounds is unrelated to zolpidem administration. Gastrointestinal function does not influence the drug’s sedative action or the client’s risk for adverse effects.
Correct Answer is ["B","D","F"]
Explanation
A. Instruct the client to stop scaring the other clients: Telling the client to stop the behavior may increase agitation and mistrust. Clients experiencing hallucinations are responding to stimuli they believe are real, so confrontation should be avoided.
B. Offer support and reassure the client being in a safe place: Providing reassurance helps decrease anxiety and fear associated with hallucinations. Calm support conveys safety and establishes trust, which are essential in managing agitation.
C. Instruct team members to ignore the client's hallucinations: Ignoring the client’s experience can worsen distress and feelings of isolation. Staff should respond therapeutically by acknowledging the client’s emotions without reinforcing the hallucination.
D. Acknowledge that the client's perception is not real to others: This approach validates the client’s feelings while gently orienting them to reality. It helps maintain rapport and avoids reinforcing false perceptions, which supports reality testing.
E. Restrict the client to his room and apply soft wrist restraints: Restraints and isolation are unnecessary unless the client poses an immediate danger to self or others. Such measures could escalate agitation and violate ethical standards of care.
F. Use simple commands in a calm, soothing voice: Clear, calm communication helps the client process information more easily. It reduces overstimulation and conveys reassurance, aiding in the de-escalation of agitation.
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