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

Choice A rationale:

Obtaining a urine specimen for analysis is an important step in the assessment of the client with renal calculi. However, it is not the most immediate intervention when the client is experiencing severe flank pain and hematuria. Pain management should take precedence.

Choice B rationale:

This is the correct answer. Severe flank pain in a client with renal calculi is indicative of renal colic, which is typically excruciating. Administering a prescribed opioid analgesic is the priority to relieve the client's pain and distress.

Choice C rationale:

Straining the urine for the presence of stones is an essential nursing intervention to identify and collect any passed stones. However, it is not the most immediate action when the client is in severe pain. Pain management is the priority.

Choice D rationale:

Preparing the client for a prescribed computed tomography (CT) scan is an important diagnostic step to assess the location and size of the renal calculi. However, it is not the most immediate intervention when the client is in severe pain and distress. Pain management should come first.

A. Move Client D into an isolation room 24 hours before surgery. B. Ask the dietitian to add a banana to Client C's breakfast tray. C. Increase Client A's oxygen to 4 liters a minute per cannula. D. Verify that Client B has two units of packed cells available.

Correct Answer is D

Explanation

The correct answer is choice d. Verify that Client B has two units of packed cells available.

Choice A rationale:

Moving Client D into an isolation room 24 hours before surgery is not necessary solely based on an elevated WBC count. Elevated WBCs indicate infection or inflammation, but isolation is not typically required unless there is a contagious infection.

Choice B rationale:

Client C’s potassium level of 3.8 mEq/L is within the normal range (3.5 to 5.0 mEq/L). Adding a banana, which is high in potassium, is not necessary.

Choice C rationale:

Client A with emphysema and an oxygen saturation of 94% does not require an increase in oxygen. Oxygen therapy should be carefully managed in clients with emphysema to avoid suppressing their respiratory drive.

Choice D rationale:

Client B has a postoperative hemoglobin of 8.2 mg/dL, which is significantly below the normal range (14 to 18 g/dL). This client may require a blood transfusion to address the low hemoglobin level, making it essential to verify the availability of packed red blood cells.

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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

Naxlex Comprehensive Predictor Exams

A client with renal calculi is experiencing hematuria and reports severe flank pain.Which intervention should the nurse implement first?

Correct Answer is B

Explanation

Correct Answer is D

Explanation

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