The nurse is caring for a patient on a telemetry unit who has a regular heart rhythm and rate of 60 beats/min; a P wave precedes each QRS complex, and the PR interval is 0.20 seconds. Additional vital signs are: blood pressure 118/68 mm Hg, respiratory rate 16 breaths/min, and temperature 98.8°F (37°C). All of these medications are available on the medication record. What action will the nurse take?
Continue to monitor.
Administer clonidine.
Administer atropine.
Administer digoxin.
The Correct Answer is A
Choice A Reason:
Continuing to monitor is the most appropriate action in this scenario. The patient has a regular heart rhythm and a heart rate of 60 beats per minute, which is within the normal range for sinus bradycardia. The PR interval is 0.20 seconds, which is at the upper limit of normal. The patient’s vital signs are stable, with a blood pressure of 118/68 mm Hg, a respiratory rate of 16 breaths per minute, and a temperature of 98.8°F (37°C). There are no signs of hemodynamic instability or symptoms that would necessitate immediate intervention. Therefore, ongoing monitoring is sufficient to ensure the patient’s condition remains stable.
Choice B Reason:
Administering clonidine is not appropriate in this situation. Clonidine is an antihypertensive medication that can lower blood pressure and heart rate. Given that the patient’s blood pressure and heart rate are within normal ranges, administering clonidine could potentially cause hypotension and bradycardia, leading to adverse effects. Therefore, clonidine is not indicated for this patient.
Choice C Reason:
Administering atropine is not necessary for this patient. Atropine is used to treat symptomatic bradycardia, where the heart rate is abnormally slow and causing symptoms such as dizziness, hypotension, or syncope. In this case, the patient’s heart rate is 60 beats per minute, which is within the normal range for sinus bradycardia, and there are no symptoms indicating the need for atropine. Therefore, atropine is not required.
Choice D Reason:
Administering digoxin is also not appropriate. Digoxin is a cardiac glycoside used to treat heart failure and certain types of arrhythmias, such as atrial fibrillation. It can slow the heart rate and increase the force of cardiac contractions. In this scenario, the patient does not have any indications for digoxin therapy, such as heart failure or atrial fibrillation, and their heart rate is already within the normal range. Therefore, digoxin is not indicated.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C"]
Explanation
Choice A Reason: High-flow nasal cannula
The high-flow nasal cannula (HFNC) is designed to deliver oxygen at flow rates much higher than 5 liters per minute, typically ranging from 20 to 60 liters per minute. It is used for patients requiring high levels of oxygen and positive airway pressure. Therefore, it is not appropriate for a flow rate of 5 liters per minute.
Choice B Reason: Simple face mask
The simple face mask is suitable for delivering oxygen at flow rates between 6 to 10 liters per minute. However, it can also be used at a flow rate of 5 liters per minute, providing an FiO2 (fraction of inspired oxygen) of approximately 40-60%. This makes it an appropriate choice for the given requirement.
Choice C Reason: Nasal cannula
The nasal cannula is a low-flow oxygen delivery device that can deliver oxygen at flow rates from 1 to 6 liters per minute. At 5 liters per minute, it provides an FiO2 of approximately 40%. It is comfortable for patients and is commonly used for those who need a moderate amount of supplemental oxygen.
Choice D Reason: Non-rebreather mask
The non-rebreather mask is designed to deliver high concentrations of oxygen, typically at flow rates of 10 to 15 liters per minute. It is used in situations where patients need a high FiO2, close to 100%. Therefore, it is not suitable for a flow rate of 5 liters per minute.
Choice E Reason: Venturi mask
The Venturi mask is used to deliver precise oxygen concentrations, typically ranging from 24% to 60% FiO2. It is suitable for patients who require controlled oxygen therapy. While it can be adjusted to deliver oxygen at a flow rate of 5 liters per minute, it is generally used for more specific FiO2 requirements.
Correct Answer is C
Explanation
Choice A Reason: Increased Serum Albumin
Increased serum albumin is not a direct indicator of the therapeutic effect of lactulose in patients with chronic hepatitis. Albumin is a protein made by the liver, and its levels can be affected by liver function. However, lactulose primarily works by reducing ammonia levels in the blood, not by increasing albumin levels. Normal serum albumin levels range from 3.5 to 5.5 grams per deciliter (g/dL). While improved liver function might eventually lead to increased albumin levels, this is not the primary therapeutic effect of lactulose.
Choice B Reason: Decreased Serum Bilirubin
Decreased serum bilirubin is also not a direct indicator of lactulose’s therapeutic effect. Bilirubin is a byproduct of the normal breakdown of red blood cells and is processed by the liver. Elevated bilirubin levels can indicate liver dysfunction, but lactulose’s main role is to reduce ammonia levels, not bilirubin. Normal serum bilirubin levels are typically between 0.1 to 1.2 milligrams per deciliter (mg/dL). While improved liver function might reduce bilirubin levels, this is not the primary goal of lactulose therapy.
Choice C Reason: Decreased Serum Ammonia
Decreased serum ammonia is the correct indicator of the therapeutic effect of lactulose in patients with chronic hepatitis. Lactulose is used to treat hepatic encephalopathy, a condition caused by high levels of ammonia in the blood due to liver dysfunction. Lactulose works by converting ammonia into ammonium, which is then excreted from the body. Normal serum ammonia levels are less than 50 micromoles per liter (µmol/L) in adults56. A decrease in serum ammonia levels indicates that lactulose is effectively reducing the toxic levels of ammonia in the blood, thereby achieving its desired therapeutic effect.
Choice D Reason: Decreased Serum Alanine Aminotransferase (ALT)
Decreased serum alanine aminotransferase (ALT) is not a direct indicator of lactulose’s therapeutic effect. ALT is an enzyme found in the liver that helps convert proteins into energy for liver cells. Elevated ALT levels can indicate liver damage. Normal ALT levels range from 7 to 56 units per liter (U/L). While improved liver function might reduce ALT levels, lactulose’s primary role is to reduce ammonia levels, not directly affect ALT.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.