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, what action should the PN take?
Administer the medication and alert the charge nurse
Hold the medication and document cardiac assessment
Administer the medication and document the heart rate
Hold the medication and recheck the heart rate in 1 hour
The Correct Answer is C
The correct answer and explanation is:
c) Administer the medication and document the heart rate.
This is the action that the PN should take prior to giving digoxin to a 2-month-old infant whose heart rate is 120 beats/minute. Digoxin is a cardiac glycoside that is used to treat heart failure and arrhythmias. It has a narrow therapeutic range and can cause serious side effects such as bradycardia, hypotension, and toxicity. Therefore, it is important to monitor the client's vital signs before and after administering the medication. A normal heart rate for a 2-month-old infant is 100–190 beats/minute, so 120 beats/minute is within the normal range and does not indicate a need to hold the medication. The PN should administer the medication as prescribed and document the heart rate and any other relevant findings.
a) Administer the medication and alert the charge nurse.
This is not the action that the PN should take prior to giving digoxin to a 2-month-old infant whose heart rate is 120 beats/minute. Alerting the charge nurse is not necessary, as the heart rate is normal and does not indicate a problem with the medication or the client's condition. The PN should administer the medication as prescribed and document the heart rate and any other relevant findings.
b) Hold the medication and document cardiac assessment.
This is not the action that the PN should take prior to giving digoxin to a 2-month-old infant whose heart rate is 120 beats/minute. Holding the medication is not appropriate, as the heart rate is normal and does not indicate a contraindication or a risk of adverse effects from the medication. The PN should administer the medication as prescribed and document the heart rate and any other relevant findings.
d) Hold the medication and recheck the heart rate in 1 hour.
This is not the action that the PN should take prior to giving digoxin to a 2-month-old infant whose heart rate is 120 beats/minute. Holding the medication and rechecking the heart rate in 1 hour is not necessary, as the heart rate is normal and does not indicate a need for further evaluation or intervention. The PN should administer the medication as prescribed and document the heart rate and any other relevant findings.
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Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
The nurse should respect the client's autonomy and right to make decisions about her own care. It is essential to honor the client's refusal of further treatment, and the nurse should communicate this to the family. In this situation, the client has the capacity to make her own decisions, and her wishes should be respected.
Choice B rationale:
Attempting to persuade the client to participate in the clinical trial for one month is not an appropriate approach. It disregards the client's autonomy and her right to refuse treatment. It's essential to respect the client's decision, and trying to convince her against her will is ethically and legally inappropriate.
Choice D rationale:
While it's important to ensure that the client fully understands the implications of her decision, doing so in front of her children may create additional pressure or discomfort for the client. The best approach is to have a private conversation with the client to assess her understanding and provide information or support as needed.
Correct Answer is A
Explanation
Choice A rationale: In a mass casualty event, the hospital must rapidly create capacity for incoming victims. Discharging stable clients who no longer require acute care is a primary nursing responsibility to free up beds and resources.
Choice B rationale: Determining the acuity and number of incoming casualties is typically the role of a triage officer or the incident commander at the scene or hospital entrance, not a floor nurse on a medical-surgical unit.
Choice C rationale: Delegating tasks to specialists or coordinating the overall medical response is the responsibility of the medical director or the designated leader in the Hospital Incident Command System (HICS), not the staff nurse.
Choice D rationale: Communication with the media is strictly handled by the Public Information Officer (PIO) to ensure accuracy and maintain client confidentiality. Staff nurses are prohibited from providing unauthorized updates to external media outlets.
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