A client is scheduled to receive atenolol 25 mg PO and diltiazem 60 mg PO at 0800. The nurse assesses the client's heart rate as 45 beats/minute and irregular. What is the best nursing action at this time?
Document the pulse rate and administer the medications as prescribed
Assess for chest pain and administer atenolol if pain free
Hold the atenolol and administer the diltiazem
Withhold the medications and reassess the heart rate in 30 minutes
The Correct Answer is C
Choice A reason: This is not the best nursing action. Documenting the pulse rate and administering the medications as prescribed may be harmful to the client. Atenolol and diltiazem are both medications that lower the blood pressure and the heart rate. Atenolol is a beta blocker that blocks the effects of adrenaline on the heart and blood vessels. Diltiazem is a calcium channel blocker that relaxes the muscles of the heart and blood vessels. Giving both medications to a client who already has a low and irregular heart rate may cause further bradycardia, which is a heart rate below 60 beats/minute, or arrhythmia, which is an abnormal heart rhythm. The nurse should check the parameters and the contraindications for the medications before administering them.
Choice B reason: This is not the best nursing action. Assessing for chest pain and administering atenolol if pain free may not be appropriate for the client. Chest pain can be a sign of angina or myocardial infarction, which are conditions where the blood flow to the heart is reduced or blocked. Atenolol can help relieve chest pain by reducing the oxygen demand of the heart, but it can also lower the heart rate and the blood pressure. The client already has a low and irregular heart rate, which may indicate a problem with the electrical conduction of the heart. The nurse should not give atenolol without checking the pulse rate and the blood pressure, and consulting the health care provider.
Choice C reason: This is the best nursing action. Holding the atenolol and administering the diltiazem is the most appropriate for the client. Atenolol can lower the heart rate and the blood pressure, which may worsen the client's condition. The nurse should hold the atenolol and notify the health care provider of the client's pulse rate and rhythm. Diltiazem can also lower the heart rate and the blood pressure, but it can also help regulate the heart rhythm by slowing down the electrical impulses in the heart. The nurse should administer the diltiazem as prescribed, and monitor the client's vital signs and cardiac status.
Choice D reason: This is not the best nursing action. Withholding the medications and reassessing the heart rate in 30 minutes may delay the treatment and the care of the client. The client has a low and irregular heart rate, which may indicate a serious cardiac problem that needs immediate attention. The nurse should not wait for 30 minutes to reassess the heart rate, but rather act promptly and notify the health care provider. The nurse should also administer the diltiazem as prescribed, unless there is a specific reason to withhold it.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: This is incorrect. Assessing the apical pulse is not enough to determine if the client is safe to receive digoxin. The client's digoxin level is already above the therapeutic range of 0.5 to 2 ng/mL¹² and giving another dose could increase the risk of toxicity and arrhythmias.
Choice B reason: This is incorrect. Administering 0.25 mcg of digoxin and potassium 20 mEq IV is not appropriate for this client. The client does not need more digoxin or potassium, as both could worsen the client's condition. Potassium levels should be monitored closely in clients taking digoxin, as low or high levels can affect the drug's action and toxicity³.
Choice C reason: This is correct. Withholding the medication and notifying the healthcare provider of the digoxin level is the most appropriate action for this client. The client's digoxin level is dangerously high and could cause serious adverse effects such as nausea, vomiting, vision changes, bradycardia, and cardiac arrest³. The healthcare provider may order to stop digoxin temporarily, adjust the dose, or prescribe an antidote such as digoxin immune fab⁴.
Choice D reason: This is incorrect. Administering the digoxin with a potassium supplement is not advisable for this client. The client's digoxin level is already too high and adding potassium could increase the risk of hyperkalemia, which can impair the heart's electrical activity and lead to cardiac arrest³. Potassium supplements should only be given to clients with digoxin-induced hypokalemia, and only under the supervision of the healthcare provider³..
Correct Answer is C
Explanation
Choice A reason: The second intercostal space, right of sternum, is not the anatomic landmark where an aortic murmur will be heard the loudest. A heart murmur is an abnormal sound that is produced by turbulent blood flow through the heart valves or chambers. ¹ An aortic murmur is a type of heart murmur that occurs when the aortic valve, which separates the left ventricle and the aorta, is damaged or diseased. ² The second intercostal space, right of sternum, is the location where the aortic valve can be best heard, but not the location where the aortic murmur will be most audible. ³
Choice B reason: The third intercostal space, left of sternum, is not the anatomic landmark where an aortic murmur will be heard the loudest. A heart murmur is an abnormal sound that is produced by turbulent blood flow through the heart valves or chambers. ¹ An aortic murmur is a type of heart murmur that occurs when the aortic valve, which separates the left ventricle and the aorta, is damaged or diseased. ² The third intercostal space, left of sternum, is the location where the pulmonary valve, which separates the right ventricle and the pulmonary artery, can be best heard, but not the location where the aortic murmur will be most audible. ³
Choice C reason: The second intercostal space, left of sternum, is the anatomic landmark where an aortic murmur will be heard the loudest. A heart murmur is an abnormal sound that is produced by turbulent blood flow through the heart valves or chambers. ¹ An aortic murmur is a type of heart murmur that occurs when the aortic valve, which separates the left ventricle and the aorta, is damaged or diseased. ² The second intercostal space, left of sternum, is the location where the aortic murmur will be most audible, as it is the closest to the aorta, the largest artery in the body. ³
Choice D reason: The fourth intercostal space, left mid-clavicular line, is not the anatomic landmark where an aortic murmur will be heard the loudest. A heart murmur is an abnormal sound that is produced by turbulent blood flow through the heart valves or chambers. ¹ An aortic murmur is a type of heart murmur that occurs when the aortic valve, which separates the left ventricle and the aorta, is damaged or diseased. ² The fourth intercostal space, left mid-clavicular line, is the location where the tricuspid valve, which separates the right atrium and the right ventricle, can be best heard, but not the location where the aortic murmur will be most audible. ³
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