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
Explanation
Choice A reason: Storing unused vials at room temperature is incorrect information that indicates a need for further education by the nurse, because somatropin is a growth hormone that should be stored in the refrigerator (2°C to 8°C) until use. Exposure to heat or light can degrade the medication and reduce its effectiveness.
Choice B reason: Rotating injection sites to minimize discomfort is correct information that does not indicate a need for further education by the nurse, because somatropin is administered subcutaneously and repeated injections at the same site can cause skin irritation, bruising, or infection.
Choice C reason: Discarding the medication if the solution is cloudy is correct information that does not indicate a need for further education by the nurse, because somatropin is a clear and colorless solution that should not be used if it appears cloudy, discolored, or contains particles. This may indicate contamination or degradation of the medication.
Choice D reason: Administering the medication subcutaneously is correct information that does not indicate a need for further education by the nurse, because somatropin is a growth hormone that is given by subcutaneous injection using a syringe or a pen device. Subcutaneous injection allows for better absorption and bioavailability of the medication.
Correct Answer is C
Explanation
Choice A reason: Beef tips with gravy are not a dietary choice that should be avoided by a client taking phenelzine, which is a monoamine oxidase inhibitor (MAOI) that treats depression. Beef tips with gravy do not contain tyramine, which is a substance that can interact with MAOIs and cause a hypertensive crisis.
Choice B reason: Deep-fried shrimp are not a dietary choice that should be avoided by a client taking phenelzine, which is a monoamine oxidase inhibitor (MAOI) that treats depression. Deep-fried shrimp do not contain tyramine, which is a substance that can interact with MAOIs and cause a hypertensive crisis.
Choice C reason: Pepperoni pizza is a dietary choice that should be avoided by a client taking phenelzine, which is a monoamine oxidase inhibitor (MAOI) that treats depression. Pepperoni pizza contains tyramine, which is a substance that can interact with MAOIs and cause a hypertensive crisis. Tyramine is found in aged, fermented, cured, smoked, or pickled foods, such as cheese, salami, sauerkraut, soy sauce, beer, and wine.
Choice D reason: Pan-seared catfish is not a dietary choice that should be avoided by a client taking phenelzine, which is a monoamine oxidase inhibitor (MAOI) that treats depression. Pan-seared catfish does not contain tyramine, which is a substance that can interact with MAOIs and cause a hypertensive crisis.
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