Which assessment finding requires nursing intervention prior to the administration of a prescribed dose of digoxin to an adult?

Apical pulse rate of 50 beats/minute.

Irregular apical pulse rhythm.

Presence of a systolic heart murmur.

Apical pulse heard best at the pulmonic site.

Answer and Explanation

The Correct Answer is A

Choice A reason: Apical pulse rate of 50 beats/minute requires nursing intervention prior to the administration of digoxin, which is a medication that slows down and strengthens the heartbeat. Digoxin can cause bradycardia, which is a slow heart rate below 60 beats/minute. Bradycardia can lead to inadequate blood flow and oxygen delivery to the body. The nurse should withhold the dose of digoxin and notify the prescriber if the apical pulse rate is below 60 beats/minute.

Choice B reason: Irregular apical pulse rhythm does not require nursing intervention prior to the administration of digoxin, which is a medication that treats arrhythmias, which are irregular heart rhythms. Digoxin can correct or prevent some types of arrhythmias, such as atrial fibrillation or flutter. The nurse should monitor the apical pulse rhythm and report any changes to the prescriber, but it is not a reason to withhold the dose of digoxin.

Choice C reason: Presence of a systolic heart murmur does not require nursing intervention prior to the administration of digoxin, which is a medication that improves the pumping function of the heart. A systolic heart murmur is a sound that occurs when the heart contracts and blood flows through a narrow or leaky valve. Digoxin can reduce the symptoms of heart failure, such as shortness of breath, fatigue, and edema, which may be associated with a systolic heart murmur. The nurse should document the presence and characteristics of the heart murmur, but it is not a reason to withhold the dose of digoxin.

Choice D reason: Apical pulse heard best at the pulmonic site does not require nursing intervention prior to the administration of digoxin, which is a medication that affects the electrical activity and contractility of the heart. The apical pulse is the heartbeat heard at the apex of the heart, which is located at the fifth intercostal space on the left midclavicular line. The pulmonic site is located at the second intercostal space on the left sternal border, where the sound of blood flow through the pulmonary valve can be heard. The nurse should listen to the apical pulse at the correct location, but it is not a reason to withhold the dose of digoxin.

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Correct Answer is D

Explanation

Choice A reason: Taking a multi-vitamin supplement daily is not a necessary instruction for a client taking warfarin, which is an anticoagulant that inhibits the synthesis of vitamin K-dependent clotting factors and prevents blood clots. However, some vitamins, such as vitamin K, vitamin E, and vitamin C, can interact with warfarin and affect its effectiveness. Patients should consult their health care provider before taking any supplements or herbal products.

Choice B reason: Using an astringent for superficial bleeding is not a sufficient instruction for a client taking warfarin, which is an anticoagulant that inhibits the synthesis of vitamin K-dependent clotting factors and prevents blood clots. Warfarin can increase the risk of bleeding, both internally and externally. Patients should report any signs of bleeding, such as bruising, nosebleeds, gum bleeding, blood in urine or stool, or prolonged bleeding from cuts or wounds, to their health care provider. They should also avoid activities or products that can increase the risk of bleeding, such as shaving with a razor, using dental floss, or taking aspirin or NSAIDs.

Choice C reason: Adding large amounts of spinach to the diet is an incorrect instruction for a client taking warfarin, which is an anticoagulant that inhibits the synthesis of vitamin K-dependent clotting factors and prevents blood clots. Spinach is a leafy green vegetable that is high in vitamin K, which can counteract the effect of warfarin and increase the risk of clotting. Patients should maintain a consistent intake of vitamin K-rich foods and avoid sudden changes in their diet.

Choice D reason: Avoiding going barefoot, especially outside, is a correct instruction for a client taking warfarin, which is an anticoagulant that inhibits the synthesis of vitamin K-dependent clotting factors and prevents blood clots. Warfarin can increase the risk of bleeding, both internally and externally. Patients should protect their feet from injury or infection by wearing shoes or slippers at all times.

A. "You can give naloxone intravenously, intramuscularly, or subcutaneously." B. "Naloxone works best on pure agonist opioids." C. "If the first dose does not work, you can give as many doses as needed to reverse respiratory depression." D. "Naloxone will not affect the client's level of pain." E. "When given IV, naloxone starts working immediately and can last several hours."

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"B"},"E":{"answers":"B"}}

Explanation

Choice A reason: This statement indicates understanding of naloxone. Naloxone is an opioid antagonist that can reverse the effects of opioid overdose, such as respiratory depression, sedation, and hypotension. Naloxone can be administered by different routes, depending on the availability and urgency of the situation. Intravenous, intramuscular, and subcutaneous routes are all acceptable ways to give naloxone.

Choice B reason: This statement also indicates understanding of naloxone. Naloxone works best on pure agonist opioids, such as morphine, heroin, and fentanyl. These opioids bind to the same receptors as naloxone, but naloxone has a higher affinity and can displace them. Naloxone is less effective on partial agonist or mixed agonist-antagonist opioids, such as buprenorphine and pentazocine. These opioids have lower intrinsic activity or antagonize some receptors, making them less susceptible to naloxone.

Choice C reason: This statement indicates no understanding of naloxone. Naloxone is not a harmless drug that can be given repeatedly without consequences. Naloxone has a short half-life of about 30 to 90 minutes, which means it can wear off before the opioid does. This can cause the patient to relapse into respiratory depression and require repeated doses of naloxone. However, giving too many doses of naloxone can also cause adverse effects, such as agitation, hypertension, tachycardia, pulmonary edema, and seizures. Therefore, naloxone should be given cautiously and titrated to the minimum effective dose to reverse respiratory depression.

Choice D reason: This statement indicates no understanding of naloxone. Naloxone will affect the client's level of pain by blocking the analgesic effects of opioids. This can cause the patient to experience acute pain and distress, especially if they have a chronic pain condition or a surgical wound. Naloxone should not be used to treat opioid-induced sedation or pruritus without respiratory depression, as this will unnecessarily expose the patient to pain and suffering.

Choice E reason: This statement indicates no understanding of naloxone. When given IV, naloxone starts working immediately, but it does not last several hours. As mentioned earlier, naloxone has a short half-life and can be eliminated from the body quickly. The duration of action of naloxone depends on the dose, route, and frequency of administration, as well as the type, dose, and route of the opioid involved. Generally, naloxone lasts for about 30 to 90 minutes when given IV, which may not be enough to counteract the longer-lasting effects of some opioids. Therefore, continuous monitoring and repeated doses of naloxone may be needed until the opioid is cleared from the system.

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Which assessment finding requires nursing intervention prior to the administration of a prescribed dose of digoxin to an adult?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client is discharged with a prescription for warfarin. Which discharge instruction should the nurse emphasize to the client?

Correct Answer is D

Explanation

Patient Data Exhibits For each statement, click to indicate whether the statements by the student nurse indicate understanding or no understanding of naloxone.

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"B"},"E":{"answers":"B"}}

Explanation

Which assessment finding requires nursing intervention prior to the administration of a prescribed dose of digoxin to an adult?

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