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
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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Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["30"]
Explanation
Question: How many mL/hour should the nurse program the infusion pump?
Step 1: Convert 176 pounds to kg. 176 lbs ÷ 2.2 = 80 kg
Step 2: Calculate the total mcg per hour. 2 mcg/min × 60 min = 120 mcg/hour
Step 3: Convert mcg to mg. 120 mcg ÷ 1000 = 0.12 mg
Step 4: Calculate the mL/hour. 0.12 mg ÷ (4 mg ÷ 1000 mL) = 30 mL/hour
Answer: 30 mL/hour
Correct Answer is D
Explanation
Choice A rationale:
Providing information about the client's healthcare power of attorney is not the most critical piece of information to report in this situation. The immediate concern is the client's change in mental status and potential medical emergency.
Choice B rationale:
While the reason for the client's admission is important background information, it is not the most urgent information to report in this situation. The priority is addressing the client's acute change in mental status.
Choice C rationale:
The nurse should be aware of the client's currently prescribed medications, but this information does not take precedence over the client's sudden onset of confusion and agitation. Immediate action is needed to address the client's altered mental status.
Choice D rationale:
Increasing confusion and agitation in a client who recently underwent ORIF of the right femur is a significant change in condition and may indicate a medical emergency such as infection, delirium, or other complications. This information should be provided first to alert the healthcare provider to the client's immediate needs.
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