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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","D","E"]
Explanation
Choice A reason:
Ibuprofen is a nonsteroidal anti-inflammatory drug (NSAID) that has analgesic, anti-inflammatory, and antipyretic effects. Ibuprofen can be prescribed along with morphine to enhance the pain relief and reduce the inflammation caused by the surgery. Ibuprofen can also reduce the opioid requirement and the risk of opioid-related side effects, such as nausea, constipation, and respiratory depression. Therefore, choice A is correct.
Choice B reason:
Propofol is a short-acting intravenous anesthetic agent that induces and maintains anesthesia and sedation. Propofol is not prescribed along with morphine for post-operative pain management, as it is not an analgesic and has a high risk of hypotension, bradycardia, and respiratory depression. Propofol is only used in controlled settings, such as the operating room or the intensive care unit, under close monitoring and supervision. Therefore, choice B is incorrect.
Choice C reason:
Methadone is a long-acting synthetic opioid that has analgesic and opioid substitution effects. Methadone is not prescribed along with morphine for post-operative pain management, as it is not indicated for acute pain and has a high risk of accumulation, overdose, and addiction. Methadone is mainly used for chronic pain or opioid dependence treatment, under strict regulation and monitoring. Therefore, choice C is incorrect.
Choice D reason:
Senna is a stimulant laxative that increases the intestinal motility and promotes bowel movements. Senna can be prescribed along with morphine to prevent or treat constipation, which is a common side effect of opioids. Senna can improve the comfort and quality of life of the client who is receiving opioid therapy. Therefore, choice D is correct.
Choice E reason:
Docusate sodium is a stool softener that increases the water content and softness of the stool. Docusate sodium can be prescribed along with morphine to prevent or treat constipation, which is a common side effect of opioids. Docusate sodium can improve the comfort and quality of life of the client who is receiving opioid therapy. Therefore, choice E is correct.
Choice F reason:
Naloxone is an opioid antagonist that reverses the effects of opioids by displacing them from their receptors. Naloxone is not prescribed along with morphine for post-operative pain management, as it would counteract the analgesic effect of morphine and cause withdrawal symptoms. Naloxone is only used in emergency situations, such as opioid overdose or respiratory depression, as a rescue medication. Therefore, choice F is incorrect.
Correct Answer is ["0.8"]
Explanation
The correct answer is 0.8 mL.
To find the answer, we can use the following formula:
(mg of medication ordered / mg of medication per mL) = mL to administer
Substituting the values from the question, we get:
(80 mg / 60 mg per 0.6 mL) = 0.8 mL
Therefore, the nurse should administer 0.8 mL of enoxaparin sodium injection.
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