The nurse is caring for a patient on a telemetry unit who has a regular heart rhythm and rate of 60 beats/min; a P wave precedes each QRS complex, and the PR interval is 0.20 seconds. Additional vital signs are: blood pressure 118/68 mm Hg, respiratory rate 16 breaths/min, and temperature 98.8°F (37°C). All of these medications are available on the medication record. What action will the nurse take?

Continue to monitor.

Administer clonidine.

Administer atropine.

Administer digoxin.

Answer and Explanation

The Correct Answer is A

Choice A Reason:

Continuing to monitor is the most appropriate action in this scenario. The patient has a regular heart rhythm and a heart rate of 60 beats per minute, which is within the normal range for sinus bradycardia. The PR interval is 0.20 seconds, which is at the upper limit of normal. The patient’s vital signs are stable, with a blood pressure of 118/68 mm Hg, a respiratory rate of 16 breaths per minute, and a temperature of 98.8°F (37°C). There are no signs of hemodynamic instability or symptoms that would necessitate immediate intervention. Therefore, ongoing monitoring is sufficient to ensure the patient’s condition remains stable.

Choice B Reason:

Administering clonidine is not appropriate in this situation. Clonidine is an antihypertensive medication that can lower blood pressure and heart rate. Given that the patient’s blood pressure and heart rate are within normal ranges, administering clonidine could potentially cause hypotension and bradycardia, leading to adverse effects. Therefore, clonidine is not indicated for this patient.

Choice C Reason:

Administering atropine is not necessary for this patient. Atropine is used to treat symptomatic bradycardia, where the heart rate is abnormally slow and causing symptoms such as dizziness, hypotension, or syncope. In this case, the patient’s heart rate is 60 beats per minute, which is within the normal range for sinus bradycardia, and there are no symptoms indicating the need for atropine. Therefore, atropine is not required.

Choice D Reason:

Administering digoxin is also not appropriate. Digoxin is a cardiac glycoside used to treat heart failure and certain types of arrhythmias, such as atrial fibrillation. It can slow the heart rate and increase the force of cardiac contractions. In this scenario, the patient does not have any indications for digoxin therapy, such as heart failure or atrial fibrillation, and their heart rate is already within the normal range. Therefore, digoxin is not indicated.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is ["B","C","E"]

Explanation

Choice A Reason:

Excessive salivation, also known as water brash, can occur in some cases of GERD, but it is not one of the most common symptoms. Water brash happens when the body produces extra saliva to neutralize the acid in the esophagus. While it can be associated with GERD, it is not as prevalent as other symptoms like heartburn or regurgitation.

Choice B Reason:

Dyspepsia, or indigestion, is a common symptom of GERD. It includes discomfort or pain in the upper abdomen, bloating, and nausea. Dyspepsia occurs because the stomach acid irritates the lining of the esophagus and stomach, leading to these uncomfortable sensations. Therefore, dyspepsia is a typical finding in patients with GERD.

Choice C Reason:

Regurgitation is a hallmark symptom of GERD. It involves the backflow of stomach contents into the esophagus and sometimes into the mouth, causing a sour or bitter taste. This symptom is due to the weakening or relaxation of the lower esophageal sphincter, which allows stomach acid to escape into the esophagus.

Choice D Reason:

Blood-tinged sputum is not a common symptom of GERD. While severe cases of GERD can lead to complications such as esophagitis or esophageal ulcers, which might cause bleeding, this is not typical in most GERD cases. Blood-tinged sputum would warrant further investigation to rule out other conditions such as infections or malignancies.

Choice E Reason:

Flatulence, or excessive gas, can be associated with GERD. The digestive process can be affected by the reflux of stomach acid, leading to increased gas production and bloating. While not as prominent as dyspepsia or regurgitation, flatulence can still be a symptom experienced by patients with GERD.

A. Administer 0.45% NS at 50 mL/h. B. Obtain daily weight. C. Maintain seizure precautions. D. Administer 3% saline as ordered. E. Encourage fluid intake.

Correct Answer is ["B","C","D"]

Explanation

Choice A Reason:

Administering 0.45% NS (normal saline) at 50 mL/h is not appropriate for a client with SIADH (Syndrome of Inappropriate Antidiuretic Hormone Secretion). This solution is hypotonic and can exacerbate the condition by increasing water retention and worsening hyponatremia. Therefore, this choice is not included in the plan of care.

Choice B Reason:

Obtaining daily weight is crucial for monitoring fluid balance in clients with SIADH. Daily weights help detect fluid retention or loss, which is essential for managing the condition. Accurate weight measurements can indicate changes in fluid status and guide adjustments in treatment.

Choice C Reason:

Maintaining seizure precautions is vital for clients with SIADH because severe hyponatremia can lead to neurological symptoms, including seizures. Implementing seizure precautions helps ensure the client’s safety and allows for prompt intervention if seizures occur.

Choice D Reason:

Administering 3% saline as ordered is appropriate for treating severe hyponatremia in clients with SIADH. Hypertonic saline helps increase serum sodium levels, which is critical for correcting the electrolyte imbalance. This intervention should be closely monitored to avoid rapid changes in sodium levels.

Choice E Reason:

Encouraging fluid intake is not appropriate for clients with SIADH. The condition is characterized by excessive water retention, and increasing fluid intake can worsen hyponatremia. Instead, fluid restriction is typically recommended to manage the condition effectively.

View Question and Answer

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is assessing a patient with gastroesophageal reflux disease (GERD). Which finding would the nurse expect to observe? Select all that apply. One, some, or all responses may be correct.

Correct Answer is ["B","C","E"]

Explanation

The nurse is planning care for a client diagnosed with SIADH. Which of the following would be included in the plan of care? Select all that apply.

Correct Answer is ["B","C","D"]

Explanation

A nurse is assessing a client who has fluid overload. Which of the following findings should the nurse expect? (Select all that apply)

For the patient with diabetes mellitus, which microvascular complication of the blood vessel structure may occur? Select all that apply. One, some, or all responses may be correct.

A client is on a ventilator. Alarms are sounding, indicating an increase in peak airway pressure. The nurse assesses first for what?

The nurse caring for mechanically ventilated clients uses best practices to prevent ventilator-associated pneumonia. What actions are included in this practice? (Select all that apply)

The nurse is monitoring the status of a postoperative client in the immediate postoperative period. The nurse would become most concerned with which sign that could indicate an evolving complication?

The nurse administers amiodarone to a client with ventricular tachycardia. Which monitoring by the nurse is necessary with this drug? (Select all that apply)

Exhibits You retrieved regular insulin 100 units in 1 ml. How many ml should you administer? Note Enter ONLY the number DO NOT enter the unit(s) of measurement