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 ["8"]
Explanation
To calculate the amount of phenytoin oral suspension to administer, we can use the following formula:
Amount to administer (mL) = (Desired dose (mg) / Available dose (mg/mL))
Plugging in the given values:
Amount to administer (mL) = (200 mg / 125 mg/5 mL)
Now, let's solve for the amount to administer:
Amount to administer (mL) = (200 mg / 125 mg/5 mL) = (200 / 125) 5 = 8
So, the nurse should administer 8 mL of phenytoin oral suspension via the gastrostomy tube.
Correct Answer is ["1"]
Explanation
To determine the number of tablets the nurse should administer for each dose, we can use the following calculation:
75 mg/day ÷ 2 doses = 37.5 mg/dose
Since 37.5 mg tablets are available, the nurse should administer 1 tablet with each dose.
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