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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
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This is the best response for the PN to provide because it sets a clear and firm boundary for the adolescent and discourages inappropriate or sexual comments. The PN should also redirect the adolescent's atention to another topic or activity and document the incident.
Correct Answer is B
Explanation
Choice A rationale:
Asking the client to describe the intensity of the eye pain using the numerical pain scale is not the most relevant action in this situation. The client's statement indicates a misconception about the purpose of pilocarpine eye drops, so addressing this misunderstanding should be the focus.
Choice B rationale:
Reminding the client that the action of the eye drops is to decrease internal eye pressure is the appropriate action. Pilocarpine eye drops are used to treat glaucoma by reducing intraocular pressure, not to anesthetize the eye.
Choice C rationale:
Documenting in the chart that the client understands the action and use of the eye drops might be necessary but should not be the first action taken. The priority is to correct the client's misunderstanding about the eye drops.
Choice D rationale:
Clarifying with the client that eye pain in glaucoma is uncommon, so drops are rarely needed, is not accurate. While eye pain might not be a common symptom of glaucoma, pilocarpine eye drops are specifically used to manage intraocular pressure and are not intended to address eye pain.
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