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:

The statement, "This medication will help regulate my mood and anxiety," is an accurate description of how antidepressants work. Antidepressants can help improve mood and reduce anxiety symptoms over time.

Choice B rationale:

This is the correct answer. Expecting immediate results from antidepressant medication is a misunderstanding. Antidepressants typically take several weeks to show their full therapeutic effects. Clients need to be informed about the delayed onset of action.

Choice C rationale:

The statement, "I may experience side effects such as nausea and drowsiness," is accurate. Antidepressants can indeed cause side effects, including gastrointestinal symptoms like nausea and drowsiness. This information is essential for the client to be aware of.

Choice D rationale:

This statement is correct. It is crucial to take antidepressant medication consistently as prescribed for the best therapeutic outcomes. Stopping or missing doses without consulting a healthcare provider can lead to treatment ineffectiveness.

A. Ask the wife to stop and assess the client's swallowing reflex. B. Give the wife a straw to help facilitate the client's drinking. C. Assist the wife and carefully give the client small sips of water. D. Obtain thickening powder before providing any more fluids.

Correct Answer is A

Explanation

The correct answer is choice a. Ask the wife to stop and assess the client’s swallowing reflex.

Choice A rationale:

Assessing the client’s swallowing reflex is crucial because facial paralysis and inability to move one side can indicate a risk of aspiration. Ensuring the client can safely swallow before giving any fluids is a priority to prevent complications like aspiration pneumonia.

Choice B rationale:

Giving the wife a straw might seem helpful, but it does not address the underlying risk of aspiration. Without assessing the swallowing reflex, using a straw could still lead to aspiration.

Choice C rationale:

Assisting the wife in giving small sips of water without assessing the swallowing reflex first is unsafe. The client might not be able to swallow properly, increasing the risk of aspiration.

Choice D rationale:

Obtaining thickening powder is a good step for clients with swallowing difficulties, but it should be done after assessing the swallowing reflex. The priority is to first determine if the client can swallow safely.

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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?

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