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 C
Explanation
This is the first action that the PN should take because the catheter size and balloon volume are inappropriate for the client. A #18 urinary catheter is too large for a female client who weighs 50 kg, and a 30 mL balloon may cause bladder trauma or discomfort. The PN should consult with the charge nurse and obtain a smaller catheter (such as #14 or #16) with a 10 mL balloon.
A. Obtaining a 30 mL syringe and a vial of sterile water is not the first action because it does not address the issue of the catheter size and balloon volume.
B. Asking the client if she has previously been catheterized is not the first action because it does not address the issue of the catheter size and balloon volume.
D. Positioning the client and observing the urinary meatus is not the first action because it does not address the issue of the catheter size and balloon volume.
Correct Answer is B
Explanation
The correct answer is choice B: Culture for sensitive organisms.
- Choice A rationale:
- C-reactive protein level - C-reactive protein (CRP) is a blood test marker for inflammation in the body. While it could indicate an infection, it is not specific enough to identify the type of infection or the causative organism.
- Choice B rationale:
- Culture for sensitive organisms - When a wound has a moderate amount of yellow and green drainage and a foul odor, it is often a sign of a bacterial infection. A culture for sensitive organisms can help identify the specific bacteria causing the infection, which is crucial for determining the most effective treatment.
- Choice C rationale:
- Serum albumin - Serum albumin levels can indicate a person’s nutritional status. Low levels can slow wound healing, but they do not directly indicate the presence of an infection.
- Choice D rationale:
- Serum blood glucose (BG) level - High blood glucose levels can impair the immune response and slow wound healing, making a person more susceptible to infections. However, like CRP, it does not provide information about the specific organism causing the infection.
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