What is the priority assessment for a 54 year old patient with heart failure who is receiving digoxin?
INR level
Temperature
Apical heart rate
Blood pressure
The Correct Answer is C
Choice A reason: This is incorrect. INR level is a measure of blood clotting time and is not directly affected by digoxin. It is more relevant for patients who are taking anticoagulants, such as warfarin.
Choice B reason: This is incorrect. Temperature is not a priority assessment for a patient receiving digoxin. It may indicate an infection or inflammation, but it is not related to the action or toxicity of digoxin.
Choice C reason: This is correct. Apical heart rate is the priority assessment for a patient receiving digoxin. Digoxin is a cardiac glycoside that increases the force and efficiency of the heart contractions, but also slows down the heart rate. The nurse should monitor the apical pulse for one full minute before administering digoxin and withhold the dose if the pulse is below 60 beats per minute for adults or below the age-specific normal range for children. A low or irregular pulse may indicate digoxin toxicity, which can be life-threatening.
Choice D reason: This is incorrect. Blood pressure is not a priority assessment for a patient receiving digoxin. Digoxin does not have a direct effect on blood pressure, although it may improve the cardiac output and reduce the fluid retention in patients with heart failure. Blood pressure should be monitored regularly, but it is not as critical as the apical heart rate.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Atenolol is a beta blocker that lowers blood pressure and heart rate. The nurse should hold atenolol for this client because the client's heart rate is already low (52 beats per minute), and giving atenolol could cause bradycardia (slow heart rate), which can lead to dizziness, fainting, or heart failure. The nurse should notify the provider and monitor the client's vital signs and cardiac rhythm.
Choice B reason: Captopril is an ACE inhibitor that lowers blood pressure and prevents kidney damage. The nurse should not hold captopril for this client because the client's blood pressure is still high (138/90 mmHg), and captopril could help lower it to the target range. The nurse should administer captopril as prescribed and monitor the client's blood pressure and renal function.
Choice C reason: Warfarin is an anticoagulant that prevents blood clots and reduces the risk of stroke. The nurse should not hold warfarin for this client because the client's INR (a measure of blood clotting time) is within the therapeutic range (2.0 to 3.0), and warfarin could help prevent post-operative complications such as deep vein thrombosis or pulmonary embolism. The nurse should administer warfarin as prescribed and monitor the client's INR and bleeding signs.
Choice D reason: Glipizide is not a medication for this client. Glipizide is an oral hypoglycemic agent that lowers blood sugar levels in people with diabetes. This client does not have diabetes and does not need glipizide. The nurse should check the medication order and the client's medical history and clarify any discrepancies with the provider.
Correct Answer is D
Explanation
Choice A reason: This choice is incorrect because it does not provide a numerical answer to the question.
Choice B reason: This choice is incorrect because it does not provide a specific answer to the question. It also implies that there is an answer that is lower than the correct one, which is not true.
Choice C reason: This choice is incorrect because it does not provide a specific answer to the question. It also implies that there is an answer that is higher than the correct one, which is not true.
Choice D reason: This choice is correct because it is the result of dividing the ordered dose (3.5 mg) by the concentration of the vial (1 mg/mL). The formula for calculating the volume to be drawn up is:
Volume = Dose/Concentration
Therefore, the volume to be drawn up is:
Volume = 3.5 mg/(1 mg/mL) = 3.5 mL
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