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 ["10"]
Explanation
The nurse needs to administer 775 mg of amoxicillin. The available amoxicillin oral suspension is 400 mg/5 mL, which means there are 400 mg of amoxicillin in every 5 mL of the suspension.
Therefore, for a 775 mg dose, the nurse should administer:
775 mg/(400 mg/5mL) = 9.6875 mL of the suspension
So, the nurse should administer approximately 10 mL (rounded to the nearest whole number).
Correct Answer is ["A","B","C","E"]
Explanation
Choice A reason: Maintaining a healthy weight is important for lowering cholesterol levels and reducing the risk of cardiovascular disease. Obesity is associated with higher levels of LDL-cholesterol (the "bad" cholesterol) and lower levels of HDL-cholesterol (the "good" cholesterol). Losing weight can improve these ratios and lower blood pressure. ¹
Choice B reason: Avoiding cigarettes and other nicotine products is essential for preventing cardiovascular disease. Smoking damages the blood vessels and increases the risk of atherosclerosis, which is the buildup of plaque in the arteries. Smoking also lowers HDL-cholesterol and raises triglycerides, another type of fat in the blood. Quitting smoking can improve cholesterol levels and lower the risk of heart attack and stroke. ²
Choice C reason: Importance of regular exercise is another key factor for improving cholesterol levels and cardiovascular health. Exercise helps to lower LDL-cholesterol and raise HDL-cholesterol, as well as lower blood pressure and blood sugar. Exercise also strengthens the heart muscle and improves blood flow. The American Heart Association recommends at least 150 minutes of moderate-intensity aerobic activity or 75 minutes of vigorous-intensity aerobic activity per week, or a combination of both. ³
Choice D reason: Positive stress management techniques are not directly related to cholesterol levels or statin medications, but they may have some benefits for cardiovascular health. Stress can increase blood pressure and heart rate, and may trigger unhealthy behaviors such as smoking, drinking, or overeating. Stress can also affect the immune system and inflammation, which may contribute to atherosclerosis. Learning to cope with stress in healthy ways, such as meditation, yoga, breathing exercises, or counseling, may help to lower the risk of cardiovascular disease. ⁴
Choice E reason: Healthy low fat diet options are an important part of lowering cholesterol levels and preventing cardiovascular disease. A diet that is high in saturated fat, trans fat, and cholesterol can raise LDL-cholesterol and lower HDL-cholesterol. A diet that is low in fat and high in fiber, fruits, vegetables, whole grains, and lean protein can lower LDL-cholesterol and raise HDL-cholesterol. Some foods, such as oats, nuts, soy, and fish, may have additional benefits for cholesterol levels. .
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