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, what action should the PN take?

Administer the medication and alert the charge nurse

Hold the medication and document cardiac assessment

Administer the medication and document the heart rate

Hold the medication and recheck the heart rate in 1 hour

Answer and Explanation

The Correct Answer is C

The correct answer and explanation is:

c) Administer the medication and document the heart rate.

This is the action that the PN should take prior to giving digoxin to a 2-month-old infant whose heart rate is 120 beats/minute. Digoxin is a cardiac glycoside that is used to treat heart failure and arrhythmias. It has a narrow therapeutic range and can cause serious side eﬀects such as bradycardia, hypotension, and toxicity. Therefore, it is important to monitor the client's vital signs before and after administering the medication. A normal heart rate for a 2-month-old infant is 100–190 beats/minute, so 120 beats/minute is within the normal range and does not indicate a need to hold the medication. The PN should administer the medication as prescribed and document the heart rate and any other relevant findings.

a) Administer the medication and alert the charge nurse.

This is not the action that the PN should take prior to giving digoxin to a 2-month-old infant whose heart rate is 120 beats/minute. Alerting the charge nurse is not necessary, as the heart rate is normal and does not indicate a problem with the medication or the client's condition. The PN should administer the medication as prescribed and document the heart rate and any other relevant findings.

b) Hold the medication and document cardiac assessment.

This is not the action that the PN should take prior to giving digoxin to a 2-month-old infant whose heart rate is 120 beats/minute. Holding the medication is not appropriate, as the heart rate is normal and does not indicate a contraindication or a risk of adverse eﬀects from the medication. The PN should administer the medication as prescribed and document the heart rate and any other relevant findings.

d) Hold the medication and recheck the heart rate in 1 hour.

This is not the action that the PN should take prior to giving digoxin to a 2-month-old infant whose heart rate is 120 beats/minute. Holding the medication and rechecking the heart rate in 1 hour is not necessary, as the heart rate is normal and does not indicate a need for further evaluation or intervention. The PN should administer the medication as prescribed and document the heart rate and any other relevant findings.

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Correct Answer is B

Explanation

The correct answer is choice b. Respiratory alkalosis.

Choice A rationale:

Metabolic alkalosis occurs when there is a loss of acid or an increase in bicarbonate in the body. This can be due to vomiting, diuretic use, or excessive bicarbonate intake. It is not typically associated with hyperventilation.

Choice B rationale:

Respiratory alkalosis is caused by hyperventilation, which leads to a decrease in carbon dioxide (CO2) levels in the blood. This condition is often triggered by anxiety, fear, pain, or fever, all of which are present in this adolescent.

Choice C rationale:

Metabolic acidosis occurs when there is an accumulation of acid or a loss of bicarbonate in the body. This can be due to conditions like diabetic ketoacidosis, renal failure, or severe diarrhea. It is not typically associated with hyperventilation.

Choice D rationale:

Respiratory acidosis occurs when there is an accumulation of CO2 in the blood due to hypoventilation or impaired lung function. This condition is not consistent with hyperventilation, which reduces CO2 levels.

A. States her feet are constantly cold along with feeling numb B. Consecutive evening serum glucose greater than 260 mg/dL C. A wound on the ankle that starts to drain and becomes painful D. Reports nausea in the morning but still able to eat breakfast

Correct Answer is B

Explanation

The correct answer and explanation is:

b) Consecutive evening serum glucose greater than 260 mg/dL.

This is the finding that the PN should document as evidence that the amount of insulin is inadequate for the client with type 1 diabetes mellitus. Consecutive evening serum glucose greater than 260 mg/dL indicates hyperglycemia, which means that the client's blood sugar is too high and not well controlled by the insulin dose.

The PN should report this finding to the healthcare provider and expect a possible adjustment in the insulin regimen.

a) States her feet are constantly cold along with feeling numb.

This is not the finding that the PN should document as evidence that the amount of insulin is inadequate for the client with type 1 diabetes mellitus.

States her feet are constantly cold along with feeling numb may indicate peripheral neuropathy, which is a complication of diabetes that aﬀects the nerves in the feet and legs. It is caused by chronic high blood sugar levels over time, not by a single dose of insulin.

c) A wound on the ankle that starts to drain and becomes painful.

This is not the finding that the PN should document as evidence that the amount of insulin is inadequate for the client with type 1 diabetes mellitus. A wound on the ankle that starts to drain and becomes painful may indicate an infection, which is a risk factor for diabetic clients due to impaired wound healing and immune function. It is not directly related to the insulin dose, although it may aﬀect the blood sugar levels and require more insulin.

d) Reports nausea in the morning but still able to eat breakfast.

This is not the finding that the PN should document as evidence that the amount of insulin is inadequate for the client with type 1 diabetes mellitus. Reports nausea in the morning but still able to eat breakfast may indicate morning sickness, which is a common symptom of pregnancy. It is not related to the insulin dose, although it may aﬀect the blood sugar levels and require more frequent monitoring and adjustment.

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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, what action should the PN take?

Nursing Test Bank

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