The nurse is preparing to administer the client's morning dose of digoxin. Which action should the nurse take prior to administering the digoxin?

Verify that the urine output exceeds 30 mL per hour.

Check the client for signs of orthostatic hypotension.

Listen to the heart at the left 5th intercostal space.

Obtain a left radial pulse rate for a full 30 seconds.

Answer and Explanation

The Correct Answer is C

A. Verify that the urine output exceeds 30 mL per hour: Although adequate urine output is important for assessing overall kidney function, it is not directly related to the safe administration of digoxin. Digoxin administration is primarily concerned with heart rate and rhythm, not renal perfusion measures before dosing.

B. Check the client for signs of orthostatic hypotension: Orthostatic hypotension assessment is valuable in many clinical scenarios but is not the primary safety check required before administering digoxin. The priority is to ensure the heart rate is sufficient and regular, as digoxin can cause bradycardia.

C. Listen to the heart at the left 5th intercostal space: Digoxin can cause significant bradycardia and arrhythmias. Therefore, the nurse must auscultate the apical heart rate at the 5th intercostal space at the midclavicular line for a full minute to determine if the rate is within safe limits for administration, 60 – 100 beats per minute in adults.

D. Obtain a left radial pulse rate for a full 30 seconds: Checking a peripheral pulse for only 30 seconds is inadequate for evaluating the cardiac effects of digoxin. Peripheral pulses may be irregular or faint in cases of dysrhythmias, leading to inaccurate assessment compared to direct apical heart auscultation.

Nursing Test Bank

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Free Nursing Study Resources

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"C"},"C":{"answers":"B"},"D":{"answers":"C"},"E":{"answers":"C"},"F":{"answers":"A"},"G":{"answers":"B"}}

Explanation

Therapeutic Result:

Semifluid stool

Non-therapeutic Side Effect:

Non-blanchable red area
Sinus tachycardia
Burning sensation

Unrelated Finding:

Pain rating 2 on pain scale of 0 to 10
Itching in legs
Blood pressure 135/81 mm Hg

Rationale:

Non-blanchable red area: A non-blanchable red area indicates localized skin damage and early pressure injury. It likely results from immobility and pressure near the buttock area, especially in a client on strict bedrest, rather than an effect of bisacodyl.
Pain rating 2 on pain scale of 0 to 10: The lower pain rating reflects effective pain management after receiving analgesics. It is a measure of comfort but not directly influenced by the administration of bisacodyl, which targets bowel function.
Sinus tachycardia: Sinus tachycardia can occur due to pain, stress, mild dehydration from increased bowel activity, or systemic response to immobility. It is not a typical response to bisacodyl use and requires further clinical monitoring.
Itching in legs: Itching is most likely related to nerve irritation, healing wounds, or dry skin from immobility rather than gastrointestinal effects. Bisacodyl does not commonly cause peripheral itching.
Blood pressure 135/81 mm Hg: Blood pressure is within a stable range and reflects the client’s cardiovascular status. It is not directly connected to bisacodyl administration or its gastrointestinal actions.
Semifluid stool: The semifluid stool is the intended therapeutic effect of bisacodyl, which stimulates peristalsis to promote bowel movement. This outcome shows the medication worked appropriately for constipation management.
Burning sensation: The burning sensation around the anus is a known side effect of rectal bisacodyl administration. Local irritation of the rectal mucosa can occur after suppository use, especially with frequent bowel movements.

Correct Answer is ["200"]

Explanation

Identify the total volume to be infused.

Total volume = 100 mL

Identify the infusion time in minutes.

Infusion time = 30 minutes

Convert the infusion time to hours.

Infusion time (hours) = Infusion time (minutes) / 60 minutes/hour

= 30 minutes / 60 minutes/hour

= 0.5 hours

Calculate the infusion rate in mL per hour.

Infusion rate (mL/hour) = Total volume (mL) / Infusion time (hours)

= 100 mL / 0.5 hours

= 200 mL/hour

View Question and Answer

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The nurse is preparing to administer the client's morning dose of digoxin. Which action should the nurse take prior to administering the digoxin?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Patient Data Review H and P, nurse's notes, flow sheet, and prescriptions. Click to mark whether the assessment finding represents a therapeutic result of the bisacodyl administered, a non-therapeutic side effect, or an unrelated finding. Each row must have one option selected.

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"C"},"C":{"answers":"B"},"D":{"answers":"C"},"E":{"answers":"C"},"F":{"answers":"A"},"G":{"answers":"B"}}

Explanation

The nurse mixes diphenhydramine 25 mg in a 100 mL bag of 0.9% sodium chloride, which is to be administered IV over 30 minutes. The IV pump should be set to administer how many mL/hour? (Enter numeric value only.)

Correct Answer is ["200"]

Explanation

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