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 A
Explanation
Choice A reason: This is correct because high lipid levels, such as cholesterol and triglycerides, are a risk factor for cardiovascular disease. HMG-CoA reductase inhibitors, also known as statins, lower the production of cholesterol in the liver and reduce the risk of heart attack and stroke.
Choice B reason: This is incorrect because blood glucose of 60 is not related to the need for an HMG-CoA reductase inhibitor. Blood glucose of 60 is below the normal range and may indicate hypoglycemia, which is a low blood sugar level. Hypoglycemia can cause symptoms such as dizziness, confusion, sweating, and hunger.
Choice C reason: This is incorrect because platelets over 150,000 are not related to the need for an HMG-CoA reductase inhibitor. Platelets are blood cells that help with clotting and prevent bleeding. The normal range of platelets is 150,000 to 450,000 per microliter of blood. Platelets over 150,000 are within the normal range and do not indicate a problem.
Choice D reason: This is incorrect because low INR is not related to the need for an HMG-CoA reductase inhibitor. INR stands for international normalized ratio and is a measure of how long it takes the blood to clot. The normal range of INR is 0.8 to 1.2. Low INR means the blood clots faster than normal and may indicate a risk of thrombosis, which is a blood clot in a vein or artery.
Correct Answer is ["0.71"]
Explanation
To calculate how many milliliters (mL) of the reconstituted medication the nurse should administer, we can use the following formula:
Desired dose (in mg) / Stock concentration (in mg/mL) = Volume to administer (in mL)
Given information:
Desired dose of ceftriaxone: 250 mg
Stock concentration after reconstitution: 350 mg/mL
Now let's calculate the volume to administer:
250 mg / 350 mg/mL = 0.7143 mL
Rounding to the nearest hundredth, the nurse should administer 0.71 mL of the reconstituted medication.
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