Which assessment finding requires nursing intervention prior to the administration of a prescribed dose of digoxin to an adult?

Apical pulse rate of 50 beats/minute.

Irregular apical pulse rhythm.

Presence of a systolic heart murmur.

Apical pulse heard best at the pulmonic site.

Answer and Explanation

The Correct Answer is A

Choice A reason: Apical pulse rate of 50 beats/minute requires nursing intervention prior to the administration of digoxin, which is a medication that slows down and strengthens the heartbeat. Digoxin can cause bradycardia, which is a slow heart rate below 60 beats/minute. Bradycardia can lead to inadequate blood flow and oxygen delivery to the body. The nurse should withhold the dose of digoxin and notify the prescriber if the apical pulse rate is below 60 beats/minute.

Choice B reason: Irregular apical pulse rhythm does not require nursing intervention prior to the administration of digoxin, which is a medication that treats arrhythmias, which are irregular heart rhythms. Digoxin can correct or prevent some types of arrhythmias, such as atrial fibrillation or flutter. The nurse should monitor the apical pulse rhythm and report any changes to the prescriber, but it is not a reason to withhold the dose of digoxin.

Choice C reason: Presence of a systolic heart murmur does not require nursing intervention prior to the administration of digoxin, which is a medication that improves the pumping function of the heart. A systolic heart murmur is a sound that occurs when the heart contracts and blood flows through a narrow or leaky valve. Digoxin can reduce the symptoms of heart failure, such as shortness of breath, fatigue, and edema, which may be associated with a systolic heart murmur. The nurse should document the presence and characteristics of the heart murmur, but it is not a reason to withhold the dose of digoxin.

Choice D reason: Apical pulse heard best at the pulmonic site does not require nursing intervention prior to the administration of digoxin, which is a medication that affects the electrical activity and contractility of the heart. The apical pulse is the heartbeat heard at the apex of the heart, which is located at the fifth intercostal space on the left midclavicular line. The pulmonic site is located at the second intercostal space on the left sternal border, where the sound of blood flow through the pulmonary valve can be heard. The nurse should listen to the apical pulse at the correct location, but it is not a reason to withhold the dose of digoxin.

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Correct Answer is D

Explanation

Choice A reason: Expectorating bronchial secretions is not an assessment information that indicates that the antitussive medication benzonatate is effective. Benzonatate is a medication that suppresses the cough reflex by numbing the throat and lungs. It does not loosen or thin the mucus in the airways, which would facilitate expectoration.

Choice B reason: Reports reduced nasal discharge is not an assessment information that indicates that the antitussive medication benzonatate is effective. Benzonatate is a medication that suppresses the cough reflex by numbing the throat and lungs. It does not affect the production or drainage of nasal secretions, which are caused by inflammation and infection in the upper respiratory tract.

Choice C reason: Able to sleep through the night is not an assessment information that indicates that the antitussive medication benzonatate is effective. Benzonatate is a medication that suppresses the cough reflex by numbing the throat and lungs. It does not have any sedative or hypnotic effects, which would promote sleep. However, by reducing coughing, benzonatate may indirectly improve the quality of sleep for the client.

Choice D reason: Denies having coughing spells is an assessment information that indicates that the antitussive medication benzonatate is effective. Benzonatate is a medication that suppresses the cough reflex by numbing the throat and lungs. It reduces the frequency and intensity of coughing, which can relieve discomfort and irritation for the client.

A. Take a multi-vitamin supplement daily. B. Use an astringent for superficial bleeding. C. Add large amounts of spinach to the diet. D. Avoid going barefoot, especially outside.

Correct Answer is D

Explanation

Choice A reason: Taking a multi-vitamin supplement daily is not a necessary instruction for a client taking warfarin, which is an anticoagulant that inhibits the synthesis of vitamin K-dependent clotting factors and prevents blood clots. However, some vitamins, such as vitamin K, vitamin E, and vitamin C, can interact with warfarin and affect its effectiveness. Patients should consult their health care provider before taking any supplements or herbal products.

Choice B reason: Using an astringent for superficial bleeding is not a sufficient instruction for a client taking warfarin, which is an anticoagulant that inhibits the synthesis of vitamin K-dependent clotting factors and prevents blood clots. Warfarin can increase the risk of bleeding, both internally and externally. Patients should report any signs of bleeding, such as bruising, nosebleeds, gum bleeding, blood in urine or stool, or prolonged bleeding from cuts or wounds, to their health care provider. They should also avoid activities or products that can increase the risk of bleeding, such as shaving with a razor, using dental floss, or taking aspirin or NSAIDs.

Choice C reason: Adding large amounts of spinach to the diet is an incorrect instruction for a client taking warfarin, which is an anticoagulant that inhibits the synthesis of vitamin K-dependent clotting factors and prevents blood clots. Spinach is a leafy green vegetable that is high in vitamin K, which can counteract the effect of warfarin and increase the risk of clotting. Patients should maintain a consistent intake of vitamin K-rich foods and avoid sudden changes in their diet.

Choice D reason: Avoiding going barefoot, especially outside, is a correct instruction for a client taking warfarin, which is an anticoagulant that inhibits the synthesis of vitamin K-dependent clotting factors and prevents blood clots. Warfarin can increase the risk of bleeding, both internally and externally. Patients should protect their feet from injury or infection by wearing shoes or slippers at all times.

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Which assessment finding requires nursing intervention prior to the administration of a prescribed dose of digoxin to an adult?

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Explanation

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