Nokea
A nurse is required to care for a child, age 4 years, who is being digitalized. Which of the following changes in the pulse rate indicates that the nurse should withhold the drug?
- A. Pulse rate less than 70 beats per minute
- B. Pulse rate less than 80 beats per minute
- C. Pulse rate less than 90 beats per minute
- D. Pulse rate more than 100 beats per minute
Correct Answer: A
Rationale: In a child, a pulse rate less than 70 beats per minute indicates toxicity. The nurse should withhold the drug when the pulse rate is less than 70 beats per minute and notify the health care provider. A pulse rate less than 60 or more than 100 beats per minute indicates toxicity in adults. A pulse rate less than 90 beats per minute indicates toxicity in infants.
You may also like to solve these questions
A client receives his prescribed daily digoxin at 9 a.m. today. The nurse would expect to obtain a serum drug level at which time?
- A. 12 noon today
- B. 4 p.m. today
- C. 9 p.m. tonight
- D. 12 midnight
Correct Answer: B
Rationale: Blood for plasma level measurements should be drawn immediately before the next dose or 6 to 8 hours after the last dose regardless of route. For this client, that would be between 3 p.m. and 5 p.m. today or immediately before his dose tomorrow.
A client is receiving maintenance therapy with digoxin. The nurse understands that which form would be used? Select all that apply.
- A. Capsule
- B. Injection
- C. Ointment
- D. Patch
- E. Tablet
Correct Answer: A,E
Rationale: Capsules and tablets are used for maintenance therapy, injections are used for rapid digitalization, and digoxin patches and ointment do not exist.
When educating a group of nursing students on the signs of heart failure, the nurse mentions that the ejection fraction is altered in heart failure. The students demonstrate understanding of the information when they identify which ejection fraction as suggesting heart failure?
- A. 38%
- B. 48%
- C. 58%
- D. 68%
Correct Answer: A
Rationale: The ejection fraction is the amount of blood that is ejected from the ventricles per beat in relation to the amount of blood available to eject. An ejection fraction of less than 40% indicates heart failure. Normally the ejection fraction should be greater than 60%.
A client has been admitted to a health care center with complaints of dyspnea. The nurse suspects left-sided heart failure based on assessment of which of the following?
- A. Nocturia
- B. Pitting edema
- C. Weight gain
- D. Orthopnea
Correct Answer: D
Rationale: The nurse should assess for orthopnea in clients with left-sided heart failure. Orthopnea is a condition where the client experiences difficulty in breathing on lying down. The other features of left ventricular failure include a hacking cough or wheezing, restlessness, and anxiety. Nocturia, pitting edema, and weight gain are associated with right-sided heart failure.
After teaching a client about his prescribed cardiotonic drug therapy, the nurse determines that additional teaching is needed when the client states which of the following?
- A. I will take the drug at the same time each day.'
- B. I can crush the tablet and mix it with food.'
- C. I should call if my pulse rate is below 80 beats per minute.'
- D. I need to notify my doctor if I have blurred vision.'
Correct Answer: C
Rationale: The client should call the primary health care provider if his pulse rate is below 60 beats per minute or above 100 beats per minute. The client should take the drug at the same time each day, crush the tablet and mix with food, and notify the primary health care provider if blurred vision occurs.