A nurse is preparing to administer belimumab 10 mg/kg via intermittent IV bolus to a client who weighs 136 lb. Available is belimumab 80 mg/mL. How many mL should the nurse administer?
(Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

Choice A reason: This is incorrect. INR level is a measure of blood clotting time and is not directly affected by digoxin. It is more relevant for patients who are taking anticoagulants, such as warfarin.

Choice B reason: This is incorrect. Temperature is not a priority assessment for a patient receiving digoxin. It may indicate an infection or inflammation, but it is not related to the action or toxicity of digoxin.

Choice C reason: This is correct. Apical heart rate is the priority assessment for a patient receiving digoxin. Digoxin is a cardiac glycoside that increases the force and efficiency of the heart contractions, but also slows down the heart rate. The nurse should monitor the apical pulse for one full minute before administering digoxin and withhold the dose if the pulse is below 60 beats per minute for adults or below the age-specific normal range for children. A low or irregular pulse may indicate digoxin toxicity, which can be life-threatening.

Choice D reason: This is incorrect. Blood pressure is not a priority assessment for a patient receiving digoxin. Digoxin does not have a direct effect on blood pressure, although it may improve the cardiac output and reduce the fluid retention in patients with heart failure. Blood pressure should be monitored regularly, but it is not as critical as the apical heart rate.

Choice A reason: This is incorrect because 30 minutes is too long to wait for reassessing a client with chest pain. Nitroglycerin has a rapid onset of action and should relieve chest pain within 5 minutes. If not, the client may need another dose or emergency care.

Choice B reason: This is correct because 5 minutes is the appropriate time to reassess a client after administering nitroglycerin sublingual. The nurse should check the client's blood pressure, heart rate, and pain level. If the pain persists, the nurse should follow the protocol for giving another dose or calling for help.

Choice C reason: This is incorrect because 1 hour is too long to wait for reassessing a client with chest pain. Nitroglycerin has a short duration of action and may need to be repeated every 5 minutes for up to 3 doses. Waiting for an hour may put the client at risk of worsening cardiac ischemia or infarction.

Choice D reason: This is incorrect because 15 minutes is too long to wait for reassessing a client with chest pain. Nitroglycerin should have an effect within 5 minutes. If the pain is not relieved by then, the client may need another dose or emergency care.