What is the priority assessment for a 54 year old patient with heart failure who is receiving digoxin?
INR level
Temperature
Apical heart rate
Blood pressure
The Correct Answer is C
Choice A reason: This is incorrect. INR level is a measure of blood clotting time and is not directly affected by digoxin. It is more relevant for patients who are taking anticoagulants, such as warfarin.
Choice B reason: This is incorrect. Temperature is not a priority assessment for a patient receiving digoxin. It may indicate an infection or inflammation, but it is not related to the action or toxicity of digoxin.
Choice C reason: This is correct. Apical heart rate is the priority assessment for a patient receiving digoxin. Digoxin is a cardiac glycoside that increases the force and efficiency of the heart contractions, but also slows down the heart rate. The nurse should monitor the apical pulse for one full minute before administering digoxin and withhold the dose if the pulse is below 60 beats per minute for adults or below the age-specific normal range for children. A low or irregular pulse may indicate digoxin toxicity, which can be life-threatening.
Choice D reason: This is incorrect. Blood pressure is not a priority assessment for a patient receiving digoxin. Digoxin does not have a direct effect on blood pressure, although it may improve the cardiac output and reduce the fluid retention in patients with heart failure. Blood pressure should be monitored regularly, but it is not as critical as the apical heart rate.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: This choice is incorrect because stomach distension and constipation are not common side effects of furosemide. They may be related to other causes, such as diet, fluid intake, or medication interactions. The nurse should assess the client's abdominal status and bowel habits and provide appropriate interventions, such as increasing fiber, fluids, or laxatives.
Choice B reason: This choice is incorrect because IV site irritation, redness, and pain are not specific side effects of furosemide. They may be caused by other factors, such as infection, infiltration, or phlebitis. The nurse should inspect the IV site and catheter and change them if needed. The nurse should also monitor the client's vital signs and blood cultures for signs of infection.
Choice C reason: This choice is correct because hearing loss or impairment is a rare but serious side effect of furosemide. It can occur due to damage to the inner ear or the auditory nerve. It may be temporary or permanent, depending on the dose and duration of furosemide therapy. The nurse should stop the infusion of furosemide and notify the provider immediately. The nurse should also assess the client's hearing and balance and provide safety measures.
Choice D reason: This choice is incorrect because frequent urination is an expected effect of furosemide. Furosemide is a diuretic that increases the excretion of water and electrolytes through the urine. It helps to reduce fluid overload and edema in clients with heart failure. The nurse should measure and record the client's intake and output and monitor the client's fluid and electrolyte status.
Correct Answer is C
Explanation
Choice A reason: This is incorrect because fentanyl 25 mcg/hr transdermal patch is a common and appropriate dose for chronic pain management. Fentanyl is a potent opioid analgesic that delivers a steady amount of medication through the skin over 72 hours.
Choice B reason: This is incorrect because meloxicam 15 mg PO daily is a standard and safe dose for treating inflammation and pain caused by arthritis. Meloxicam is a nonsteroidal anti-inflammatory drug (NSAID) that reduces the production of prostaglandins, which are involved in inflammation.
Choice C reason: This is correct because regular insulin 8 units subcutaneous before meals is a vague and potentially dangerous prescription. Regular insulin is a short-acting insulin that lowers blood glucose levels by facilitating the uptake of glucose into the cells. The dose of insulin should be individualized based on the client's blood glucose level, carbohydrate intake, and activity level. The nurse should contact the provider for clarification on how to adjust the dose according to the client's needs.
Choice D reason: This is incorrect because docusate sodium 200 mg PO at bedtime is a usual and effective dose for preventing constipation. Docusate sodium is a stool softener that works by increasing the amount of water in the stool, making it easier to pass.
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