A nurse is reviewing the medication administration record of a client who is receiving digoxin, a cardiac glycoside. The nurse notes that the client's apical pulse is 58 beats per minute. Which of the following actions should the nurse take?

Administer the medication as prescribed.

Hold the medication and notify the provider.

Check the client's blood pressure and oxygen saturation.

Repeat the apical pulse measurement after 5 minutes.

Answer and Explanation

The Correct Answer is C

Checking the client's blood pressure and oxygen saturation is an appropriate action for the nurse to take when the client's apical pulse is below 60 beats per minute, which is the lower limit of normal. This is because a low pulse rate can indicate bradycardia, which can affect the client's hemodynamic status and tissue perfusion.

A and B are incorrect. Administering the medication as prescribed or holding the medication and notifying the provider are not appropriate actions for the nurse to take without further assessment of the client's condition. Digoxin can lower the heart rate, but it can also improve cardiac output and contractility in clients with heart failure. Therefore, the nurse should not withhold the medication based on one vital sign measurement alone.

D is incorrect. Repeating the apical pulse measurement after 5 minutes is not an appropriate action for the nurse to take when the client's apical pulse is below 60 beats per minute, as it delays further assessment and intervention.

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Correct Answer is ["A","B","D"]

Explanation

A) This is correct as the INR level measures how long it takes for blood to clot and is used to monitor the effectiveness and safety of warfarin therapy. A high INR level indicates a higher risk of bleeding.

B) This is correct as some herbal supplements, such as garlic, ginger, ginkgo, and ginseng, can interact with warfarin and increase the risk of bleeding.

C) This is incorrect as vitamin K-rich foods, such as green leafy vegetables, can interfere with warfarin and decrease its effectiveness, leading to a lower risk of bleeding. However, clients taking warfarin should maintain a consistent intake of vitamin K-rich foods and avoid sudden changes in their diet.

D) This is correct as peptic ulcer disease is a condition that causes erosion and inflammation of the lining of the stomach or duodenum and can lead to bleeding complications, especially when taking warfarin.

E) This is incorrect as blood pressure does not directly affect the risk of bleeding from warfarin therapy. However, clients taking warfarin should monitor their blood pressure regularly and report any signs of hypertension or hypotension to their provider.

A. Use a latex-free syringe and needle. B. Wear non-latex gloves when handling the injection site. C. Apply a non-latex bandage over the injection site after giving the injection. D. Check the medication label for any latex components. E. Ask the client about any previous reactions to latex products.

Correct Answer is ["D","E"]

Explanation

Checking the medication label for any latex components and asking the client about any previous reactions to latex products are important precautions that can help prevent an allergic reaction. Some medications may contain latex in their packaging or formulation, and some clients may have more severe reactions than others.

A, B, and C are incorrect. Using a latex-free syringe and needle, wearing non-latex gloves, and applying a non-latex bandage are not precautions, but rather standard practices for administering an intramuscular injection to any client.

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A nurse is reviewing the medication administration record of a client who is receiving digoxin, a cardiac glycoside. The nurse notes that the client's apical pulse is 58 beats per minute. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reviewing a client's medication list and notices that the client is taking warfarin, a blood thinner. Which of the following factors should the nurse assess as potential risk factors for bleeding? (Select all that apply.)

Correct Answer is ["A","B","D"]

Explanation

A nurse is administering an intramuscular injection to a client who has a latex allergy. Which of the following precautions should the nurse take to prevent an allergic reaction? (Select all that apply.)

Correct Answer is ["D","E"]

Explanation

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