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
The correct answer is Choice C. Following abdominal surgery, a client experiences wound evisceration.
Choice A rationale:
Cellulitis developing around a foot wound in a client with diabetes mellitus (DM) is a concerning situation, but it does not require the most immediate intervention compared to wound evisceration. Cellulitis is a bacterial skin infection that can usually be treated with antibiotics, while wound evisceration is a surgical emergency.
Choice B rationale:
Following suture removal from a stab wound, wound dehiscence is a serious complication, but it is not as immediately life-threatening as wound evisceration. Wound dehiscence is the separation of the wound edges after closure, and while it requires prompt attention, it does not involve the protrusion of organs from the wound.
Choice C rationale:
Wound evisceration, the protrusion of organs through a surgical incision, is a life-threatening complication that requires immediate intervention. The practical nurse should cover the exposed organs with a sterile, moist dressing and seek immediate medical assistance to prevent infection and further complications.
Choice D rationale:
For a client with a stage 4 sacral pressure ulcer developing purulent drainage is a concern, but it is not as immediately critical as wound evisceration. Proper wound care and infection management are essential, but the urgency level is lower compared to wound evisceration.
Correct Answer is D
Explanation
The correct answer is choice D. Electrolytes.
Choice A rationale:
White blood cell count (WBC) is primarily used to detect infections, inflammation, and immune system disorders.While an abnormal WBC count can indicate various health issues, it is not directly related to numbness and tingling in the extremities.
Choice B rationale:
Hematocrit measures the proportion of red blood cells in the blood. It is useful for diagnosing anemia and other blood disorders.However, hematocrit levels are not typically associated with symptoms of numbness and tingling.
Choice C rationale:
Albumin and protein levels are important for assessing nutritional status and liver function.Low levels can indicate malnutrition or liver disease, but they are not directly linked to the sensation of numbness and tingling in the extremities.
Choice D rationale:
Electrolytes, such as sodium, potassium, calcium, and magnesium, play a crucial role in nerve function and muscle contraction. Imbalances in electrolyte levels can lead to symptoms like numbness, tingling, and muscle cramps.Therefore, reviewing the client’s electrolyte levels is essential when they report these symptoms.
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