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 ["5"]
Explanation
To calculate the amount of megestrol oral suspension that the nurse should administer, we can use the following formula:
Amount to administer (mL) = (Desired dose in mg) / (Amount of drug in 1 mL)
Given:
Desired dose = 200 mg
Amount of drug in 1 mL = 40 mg/mL
Now, let's calculate the amount to administer:
Amount to administer (mL) = 200 mg / 40 mg/mL
Amount to administer (mL) = 5 mL
Rounding to the nearest whole number, the nurse should administer 5 mL of the megestrol oral suspension.
Correct Answer is D
Explanation
Choice A reason: This is incorrect because a dry cough is not a common or serious side effect of hydralazine. A dry cough is more likely to occur with angiotensin-converting enzyme (ACE) inhibitors, which are another class of antihypertensive drugs.
Choice B reason: This is incorrect because hydralazine does not cause a low heart rate. In fact, hydralazine can cause a reflex increase in heart rate as a result of lowering the blood pressure. This is why hydralazine is often given with a beta-blocker, which can slow down the heart rate.
Choice C reason: This is incorrect because hydralazine does not interact with birth control. However, the nurse should advise the client to use effective contraception while taking hydralazine, as this medication can cause fetal harm if used during pregnancy.
Choice D reason: This is correct because hydralazine can cause orthostatic hypotension, which is a sudden drop in blood pressure when changing positions. This can lead to dizziness, fainting, and falls. The nurse should instruct the client to avoid getting up too quickly and to ask for assistance if needed.
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