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 C
Explanation
Choice A reason: This is incorrect because fentanyl 25 mcg/hr transdermal patch is a common and appropriate dose for chronic pain management. Fentanyl is a potent opioid analgesic that delivers a steady amount of medication through the skin over 72 hours.
Choice B reason: This is incorrect because meloxicam 15 mg PO daily is a standard and safe dose for treating inflammation and pain caused by arthritis. Meloxicam is a nonsteroidal anti-inflammatory drug (NSAID) that reduces the production of prostaglandins, which are involved in inflammation.
Choice C reason: This is correct because regular insulin 8 units subcutaneous before meals is a vague and potentially dangerous prescription. Regular insulin is a short-acting insulin that lowers blood glucose levels by facilitating the uptake of glucose into the cells. The dose of insulin should be individualized based on the client's blood glucose level, carbohydrate intake, and activity level. The nurse should contact the provider for clarification on how to adjust the dose according to the client's needs.
Choice D reason: This is incorrect because docusate sodium 200 mg PO at bedtime is a usual and effective dose for preventing constipation. Docusate sodium is a stool softener that works by increasing the amount of water in the stool, making it easier to pass.
Correct Answer is C
Explanation
Choice A reason: Diet cola PO is not an appropriate recommendation for a client with a blood glucose of 30, because diet cola does not contain any sugar and will not raise the blood glucose level. Moreover, the client is lethargic and unable to follow commands, which means they may have difficulty swallowing and may aspirate the liquid.
Choice B reason: Dextrose 50% IV is a potential recommendation for a client with a blood glucose of 30, because it can rapidly increase the blood glucose level and reverse the symptoms of hypoglycemia. However, the nurse is unable to get an IV line started on the client, which makes this option impossible.
Choice C reason: Glucagon IM is the best recommendation for a client with a blood glucose of 30, because it can stimulate the liver to release glucose into the bloodstream and raise the blood glucose level. Glucagon can be given intramuscularly or subcutaneously, which does not require an IV access. Glucagon is usually given as an emergency treatment for severe hypoglycemia when the client is unconscious or unable to swallow.
Choice D reason: Insulin glargine SQ is not an appropriate recommendation for a client with a blood glucose of 30, because insulin glargine is a long-acting insulin that lowers the blood glucose level. Giving insulin to a client with hypoglycemia can worsen their condition and cause coma or death. ⁹
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