Prior to giving digoxin, the practical nurse (PN) assesses that a 2-month-old infant's heart rate is 120 beats/minute. Based on this finding, which action should the PN take?
Hold the medication and recheck the heart rate in l hour.
Administer the medication and document the heart rate.
Administer the medication and alert the charge nurse.
Hold the medication and document cardiac assessment.
The Correct Answer is B
Digoxin is a medication used to treat various heart conditions, such as abnormal heart rhythms and heart failure. It works by improving the strength and efficiency of the heart, or by controlling the rate and rhythm of the heartbeat.
One of the important things to monitor when giving digoxin to an infant is the pulse rate. Digoxin can lower the heart rate, which can be dangerous if it becomes too slow. Therefore, the pulse rate should be checked for one full minute before administering digoxin, and the medication should be held if the pulse rate is below 90 beats per minute (bpm) for an infant.
In this case, the infant’s heart rate is 120 bpm, which is within the normal range for a 2-month-old. Therefore, the correct action for the PN to take is to administer the medication and document the heart rate. This is option b in the list of choices. Option a is incorrect because there is no need to hold the medication or recheck the heart rate in one hour. Option c is incorrect because there is no need to alert the charge nurse unless there is a problem with the infant’s condition or the medication. Option d is incorrect because holding the medication and documenting cardiac assessment is not appropriate for a normal heart rate.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The correct answer is choiced. Explains importance of wearing protective clothing when outdoors.
Choice A rationale:
Maintaining a current immunization schedule is important for overall health, but it is not directly related to Lyme disease prevention or management, as there is no vaccine for Lyme disease in humans.
Choice B rationale:
Wearing a mask when leaving the room is a precaution for airborne diseases, not for Lyme disease, which is transmitted through tick bites.
Choice C rationale:
Disposal of personal tissues in a no-touch receptacle is a general infection control measure but does not specifically address Lyme disease prevention or management.
Choice D rationale:
Wearing protective clothing when outdoors is crucial for preventing tick bites, which are the primary mode of transmission for Lyme disease. This measure directly addresses the prevention of Lyme disease.
Correct Answer is B
Explanation
The correct answer is choice B. Attach the drainage bag to the bed frame.
Choice A rationale:
Measuring the urinary output in the bag is a routine task but does not address the improper placement of the drainage bag. The immediate concern is to ensure the drainage bag is correctly positioned to prevent complications.
Choice B rationale:
Attaching the drainage bag to the bed frame is the correct action. The drainage bag should be kept below the level of the bladder and attached to a non-movable part of the bed to prevent backflow and reduce the risk of infection.
Choice C rationale:
Applying gloves and emptying the drainage bag is not the immediate priority. The drainage bag should not be allowed to overfill, but in this scenario, it is only half-full, so this action is not urgent.
Choice D rationale:
Removing the looped tubing from the bed is important to ensure proper drainage and prevent backflow, but it does not address the incorrect placement of the drainage bag, which is the primary concern in this situation.
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