A nurse is preparing to administer digoxin to a client.
For which of the following findings should the nurse withhold the medication?

Apical pulse 54/min.

Respiratory rate 14/min.

BP 179/89 mm Hg.

Temperature 37.8° C (100° F)

Answer and Explanation

The Correct Answer is A

Choice A rationale:

An apical pulse of 54/min is below the normal range for adults. Digoxin, a cardiac medication, can lower the heart rate. Therefore, it’s crucial to hold the medication if the resting pulse for an adult is less than 60 bpm. This is to prevent further lowering of the heart rate which could lead to bradycardia, a potentially dangerous condition.

Choice B rationale:

A respiratory rate of 14/min is within the normal adult range of 12-20 breaths per minute. This would not be a reason to withhold digoxin.

Choice C rationale:

A blood pressure (BP) of 179/89 mm Hg indicates hypertension, which is not a direct contraindication for digoxin. However, it’s important to monitor BP levels in clients taking digoxin as the medication can affect blood pressure.

Choice D rationale:

A temperature of 37.8° C (100° F) is slightly elevated but would not be a reason to withhold digoxin unless it’s indicative of an underlying infection that needs to be addressed first.

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Correct Answer is D

Explanation

Choice A rationale:

Oxycodone overdose typically results in constricted (not dilated) pupils due to its action on the central nervous system.

Choice B rationale:

Oxycodone overdose can cause respiratory depression, leading to slow and shallow breathing (bradypnea), not rapid breathing (tachypnea)

Choice C rationale:

Oxycodone does not typically cause tachycardia. It can cause bradycardia due to its action on the central nervous system.

Choice D rationale:

Sedation is a common effect of oxycodone and can be more pronounced in cases of overdose due to the drug’s depressant effect on the central nervous system.

A. "Using morphine PCA increases the client's risk of toxicity.” B. "Diarrhea is an adverse effect of morphine PCA.” C. "Check the client's pain level every 8 hours.” D. "Instruct the client's visitors not to operate the PCA pump.”

Correct Answer is D

Explanation

Choice Arationale:

Using PCA does not necessarily increase the client’s risk of toxicity. PCA allows the client to self-administer preset doses of pain medication, which can lead to better pain control with less risk of overdose.

Choice B rationale:

Diarrhea is not a common adverse effect of morphine. Constipation, not diarrhea, is a common side effect due to slowed gastrointestinal motility.

Choice Crationale:

Checking the client’s pain level every 8 hours is not sufficient when using PCA. Pain levels should be assessed more frequently, ideally before and after each administration of the medication. This allows for timely adjustments to the medication regimen if needed.

Choice D rationale:

Instructing the client’s visitors not to operate the PCA pump is crucial. Only the patient should administer doses to prevent overdose.

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A nurse is preparing to administer digoxin to a client.For which of the following findings should the nurse withhold the medication?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is collecting data from a client who has taken an overdose of oxycodone.Which of the following findings should the nurse expect?

Correct Answer is D

Explanation

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Correct Answer is D

Explanation

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A nurse is preparing to administer digoxin to a client.
For which of the following findings should the nurse withhold the medication?