The nurse is auscultating a 6-month-old client’s apical heart rate before giving a dose of digoxin and notes that the heart rate is 89 beats per minute. Which action should the nurse take?
Withhold the digoxin and assess for signs of decreased cardiac output and digoxin toxicity
Withhold the digoxin and re-evaluate the heart rate in 4 hours
Administer half of the prescribed dose to avoid further decrease in heart rate
Administer the digoxin; the heart rate would be considered normal because of the client’s age
The Correct Answer is A
Choice A reason: A heart rate of 89 beats per minute in a 6-month-old (normal 90–160) is low, indicating potential digoxin toxicity or decreased cardiac output. Withholding digoxin and assessing for symptoms like nausea or arrhythmias is critical to prevent harm, making this the correct action for the nurse.
Choice B reason: Withholding digoxin and re-evaluating in 4 hours delays necessary assessment for toxicity or cardiac compromise in a 6-month-old with a low heart rate (89 bpm). Immediate evaluation is needed, making this incorrect, as it risks missing critical signs of digoxin-related complications.
Choice C reason: Administering half the digoxin dose is unsafe without confirming the cause of the low heart rate (89 bpm). In infants, this could worsen toxicity or bradycardia. Withholding and assessing for toxicity is safer, making this an incorrect action for managing potential digoxin complications.
Choice D reason: A heart rate of 89 bpm is below normal for a 6-month-old (90–160 bpm), and administering digoxin risks worsening bradycardia or toxicity. Normal infant heart rates are higher, making this incorrect, as the nurse must withhold the dose and assess for complications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Laying the infant with the head lower than the body worsens cyanosis in tetralogy of Fallot by reducing systemic venous return. The knee-to-chest position increases resistance, improving oxygenation, making this incorrect, as it indicates a need for further teaching on proper positioning.
Choice B reason: Holding the infant against the shoulder with knees bent up toward the chest is the correct knee-to-chest position for tetralogy of Fallot during cyanosis. This increases systemic vascular resistance, reducing right-to-left shunting and improving oxygenation, indicating the father’s understanding of the instructions.
Choice C reason: Placing the infant upright in an infant seat does not effectively increase systemic vascular resistance to reduce shunting in tetralogy of Fallot. The knee-to-chest position is required, making this incorrect, as it shows a need for teaching on the correct positioning to manage cyanosis.
Choice D reason: Supine position with head elevated does not address cyanosis in tetralogy of Fallot, as it fails to increase systemic resistance to reduce shunting. Knee-to-chest positioning is needed, making this incorrect, as it indicates misunderstanding of the proper technique to improve oxygenation.
Correct Answer is C
Explanation
Choice A reason: Secondary hypertension has an identifiable cause, like renal disease, and accounts for about 10% of cases. Primary hypertension, with no known cause, is far more common, making this an incorrect term, as it does not describe the majority of hypertension cases seen clinically.
Choice B reason: Malignant hypertension is a severe, rapidly progressing form with organ damage, not the common form of hypertension. Primary hypertension, with no identifiable cause, represents 90% of cases, making this term incorrect, as it refers to a rare, acute condition, not the typical presentation.
Choice C reason: Primary hypertension, also called essential hypertension, has no identifiable cause and accounts for approximately 90% of cases. It develops gradually, influenced by genetics and lifestyle, making this the correct term to describe the most common form of persistently elevated blood pressure.
Choice D reason: Accelerated hypertension involves rapid blood pressure elevation with organ damage, not the typical chronic, idiopathic form. Primary hypertension, without a known cause, is the predominant type, making this term incorrect, as it describes a severe, less common variant of hypertension.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.