The nurse is preparing a patient’s daily dose of digoxin (Lanoxin), an inotropic drug. The adult patient has an apical pulse of 48/min.
What should the nurse do next?
Withhold the dose and notify the health care provider.
Notify the health care provider and monitor the patient’s vital signs.
Recheck the pulse, making sure to count for 1 full minute.
Administer the dose.
The Correct Answer is A
Digoxin is a medication that can help the heart pump more blood and slow down the heart rate in certain conditions, such as heart failure and atrial fibrillation. However, digoxin has a narrow therapeutic range, which means that too much or too little of it can be harmful. The therapeutic range of digoxin levels in the blood is 0.5-2 ng/mL, and the toxic level is >2.4 ng/mL. Digoxin should be held if the resting apical pulse of an infant is <90 bpm, an older child is <70 bpm, or an adult is <60 bpm. A pulse of 48/min in an adult is too low and could indicate digoxin toxicity, which can cause life-threatening arrhythmias. Therefore, the nurse should withhold the dose and notify the health care provider immediately.
Choice B is wrong because notifying the health care provider and monitoring the patient’s vital signs are not enough.
The nurse should also withhold the dose to prevent further exposure to digoxin.
Choice C is wrong because rechecking the pulse, making sure to count for 1 full minute, is not necessary. The nurse should already have counted the pulse for 1 full minute before administering digoxin, as per standard procedure.
Choice D is wrong because administering the dose could worsen the patient’s condition and increase the risk of digoxin toxicity and arrhythmias.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Furosemide is a diuretic that lowers blood pressure and increases urine output. It also causes potassium loss, which can lead to hypokalemia (low potassium levels). The patient’s blood pressure is already low when sitting, and the serum potassium is below the normal range of 3.5 to 5.0 mEq/L. Administering furosemide could worsen these conditions and cause adverse effects such as dehydration, dizziness, muscle weakness, cardiac arrhythmias, and renal impairment. Therefore, the nurse should contact the provider before giving the medication and report the vital signs and laboratory results.
Choice A. Administer medication is wrong because it could harm the patient as explained above.
Choice C. Hold medication until next dose is wrong because it does not address the underlying problem of fluid retention and hypokalemia.
The nurse should not delay notifying the provider about the patient’s condition.
Choice D. Check urine output before giving medication is wrong because it is not enough to ensure the patient’s safety.
The nurse should also check the blood pressure and serum potassium levels, which are more critical indicators of the patient’s status.
Correct Answer is B
Explanation
PT stands for prothrombin time, which is a measure of how long it takes the blood to clot.
INR stands for international normalized ratio, which is a way of standardizing the PT results across different laboratories.
Warfarin is a blood thinner that works by inhibiting the production of vitamin K-dependent clotting factors in the liver.
Therefore, warfarin prolongs the PT and increases the INR.The PT/INR test is used to monitor the effectiveness of warfarin therapy and adjust the dose accordingly.
Choice A is wrong because PTT stands for partial thromboplastin time, which is another measure of blood clotting time, but it reflects the activity of different clotting factors than PT.PTT is used to monitor heparin therapy, not warfarin therapy.
Choice C is wrong because aPTT stands for activated partial thromboplastin time, which is a variation of PTT that uses an activator to speed up the clotting time.Like PTT, aPTT is used to monitor heparin therapy, not warfarin therapy.
Choice D is wrong because ACT stands for activated clotting time, which is a measure of the whole blood clotting time.ACT is used to monitor high-dose heparin therapy during certain procedures, such as cardiac bypass surgery or angioplasty.
The normal ranges for these tests may vary depending on the laboratory and the method used, but generally, they are:
• PT: 10 to 13 seconds
• INR: 0.8 to 1.2 (without warfarin) or 2.0 to 3.0 (with warfarin)
• PTT: 25 to 35 seconds
• aPTT: 30 to 40 seconds
• ACT: 70 to 120 seconds
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