A patient is ordered to receive digoxin to treat congestive heart failure. The nurse is most concerned about which assessment finding.
RR 18 bpm
1+ pitting edema of the lower extremities
BP 138/90 mm Hg
Heart rate 54 beats/min
The Correct Answer is D
A) RR 18 bpm:
A respiratory rate of 18 breaths per minute is within the normal range for adults (12-20 bpm). Therefore, this finding does not pose a significant concern in the context of digoxin therapy. Respiratory rate should be monitored, especially if the patient is experiencing signs of heart failure or digoxin toxicity, but 18 bpm alone is not alarming.
B) 1+ pitting edema of the lower extremities:
Pitting edema, especially with a grade of 1+ (slight indentation), is a common finding in patients with congestive heart failure (CHF). It indicates fluid retention due to the heart's inability to pump blood effectively. While edema should be monitored, it is not immediately life-threatening or specific to digoxin toxicity.
C) BP 138/90 mm Hg:
A blood pressure of 138/90 mm Hg is slightly elevated, but it is not excessively high. This finding is manageable and should be monitored, particularly in heart failure patients, but it does not present an immediate concern in this case. Blood pressure management is crucial in CHF, but it does not directly correlate with digoxin toxicity.
D) Heart rate 54 beats/min:
A heart rate of 54 beats per minute is considered bradycardic, especially in a patient taking digoxin. Digoxin can lower heart rate by increasing vagal tone and inhibiting the AV node. Bradycardia is a well-known sign of digoxin toxicity, and this finding is concerning because it may indicate that the patient is experiencing toxicity. Digoxin-induced bradycardia can lead to more serious arrhythmias or hemodynamic instability, making this the most concerning finding that requires immediate assessment and possibly intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A) Cardizem:
Cardizem (diltiazem) is a calcium channel blocker. Calcium channel blockers work by inhibiting the entry of calcium into the smooth muscle cells of the heart and blood vessels, which helps relax the blood vessels and lower blood pressure.
B) Labetalol:
Labetalol is a beta blocker and an alpha-1 blocker. It works by blocking both beta-adrenergic receptors (which help decrease heart rate and blood pressure) and alpha-1 receptors (which cause vasodilation). This dual action makes labetalol effective in treating high blood pressure, especially in patients with conditions like hypertension and hypertensive emergencies. It reduces heart rate and helps relax blood vessels, improving blood flow.
C) Losartan:
Losartan is an angiotensin II receptor blocker (ARB). ARBs work by blocking the effects of angiotensin II, a hormone that causes blood vessels to constrict. By blocking this effect, losartan helps lower blood pressure and is used in the treatment of hypertension and heart failure.
D) Simvastatin:
Simvastatin is a statin, which is a medication used to lower cholesterol levels. Statins work by inhibiting an enzyme involved in cholesterol production in the liver. They are used primarily to manage high cholesterol and reduce the risk of heart disease, but they do not have an effect on heart rate or blood pressure, unlike beta blockers.
Correct Answer is D
Explanation
Given:
Volume of Glucerna 1.2: 237 mL
Desired concentration: 1/2 strength
Step 1: Determine the volume of Glucerna 1.2 needed for the half-strength solution:
Volume of Glucerna 1.2 for half-strength = Original volume / 2
Volume of Glucerna 1.2 for half-strength = 237 mL / 2
Volume of Glucerna 1.2 for half-strength = 118.5 mL
Step 2: Calculate the amount of water to be added:
Amount of water = Original volume - Volume of Glucerna 1.2 for half-strength
Amount of water = 237 mL - 118.5 mL
Amount of water = 118.5 mL
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