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HESI PN EXIT Exam Two
HESI PN EXIT Exam Two ( 75 Questions)
Prior to giving digoxin, the practical nurse (PN) assesses that a 2-month-old infant's heart rate is 120 beats/minute. Based on this finding, which action should the PN take?
This option suggests delaying the administration of the medication without clear justification. If the healthcare provider has prescribed the medication and the heart rate is within an acceptable range, delaying it without a specific reason may not align with the provider's instructions.
However, it's crucial to emphasize that the nurse should always follow the specific orders and guidelines of the healthcare provider and the facility's protocols. If there is any uncertainty or concern, the nurse should seek guidance from the charge nurse or the healthcare provider before taking any action.
Administering the medication and immediately alerting the charge nurse without a clear indication of a problem might create unnecessary concern or confusion. The nurse should follow the established protocols and guidelines, and if there are concerns, consulting with the healthcare provider may be more appropriate before alerting others.
This option involves holding the medication without clear justification or evidence of a contraindication. If the heart rate is within the acceptable range and the healthcare provider has ordered the medication, holding it without proper reason might not be in line with best practices.
In the absence of specific medical guidelines or orders, and considering the heart rate of 120 beats per minute, the generally appropriate course of action for a practical nurse might be to administer the medication as ordered by the healthcare provider. Therefore, the correct choice could be:
b) Administer the medication and document the heart rate.
However, it's crucial to emphasize that the nurse should always follow the specific orders and guidelines of the healthcare provider and the facility's protocols. If there is any uncertainty or concern, the nurse should seek guidance from the charge nurse or the healthcare provider before taking any action.
a) Hold the medication and recheck the heart rate in 1 hour:
- Rationale: This option suggests delaying the administration of the medication without clear justification. If the healthcare provider has prescribed the medication and the heart rate is within an acceptable range, delaying it without a specific reason may not align with the provider's instructions.
c) Administer the medication and alert the charge nurse:
- Rationale: Administering the medication and immediately alerting the charge nurse without a clear indication of a problem might create unnecessary concern or confusion. The nurse should follow the established protocols and guidelines, and if there are concerns, consulting with the healthcare provider may be more appropriate before alerting others.
d) Hold the medication and document cardiac assessment:
- Rationale: This option involves holding the medication without clear justification or evidence of a contraindication. If the heart rate is within the acceptable range and the healthcare provider has ordered the medication, holding it without proper reason might not be in line with best practices.
It's important to note that the appropriateness of actions depends on the specific clinical context, healthcare provider's orders, and facility protocols. Always consult with a healthcare professional or follow the established guidelines in your healthcare setting.