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 is incorrect. Dry cough and nose bleed are not common side effects of gemfibrozil. They may indicate other conditions, such as allergies, infections, or bleeding disorders.
Choice B reason: This is incorrect. Constipation and dry skin are not common side effects of gemfibrozil. They may be caused by dehydration, dietary factors, or other medications.
Choice C reason: This is correct. Abdominal pain and jaundice are serious side effects of gemfibrozil. They may indicate liver damage, which can be fatal if not treated promptly. The client should report these symptoms to the prescriber immediately.
Choice D reason: This is incorrect. Hirsutism and flatulence are not common side effects of gemfibrozil. They may be associated with hormonal imbalances, digestive disorders, or other causes.
Correct Answer is ["0.4"]
Explanation
Given:
Enoxaparin dose: 40 mg
Available concentration: 100 mg/mL
Step 1: Calculate the volume of enoxaparin to be administered in mL
Volume = Enoxaparin dose / Concentration
Volume = 40 mg / 100 mg/mL
Volume = 0.4 mL
Rounding to the nearest tenth:
Volume = 0.4 mL
Therefore, the nurse should administer 0.4 mL of enoxaparin subcutaneously for the prevention of deep vein thrombosis.
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