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A patient about to receive a morning dose of digoxin has an apical pulse of 53 beats/min. What will the nurse do next?
- A. Administer the dos
- C. Administer the dose, and notify the prescriber.
- D. Check the radial pulse for 1 full minut
Correct Answer: D
Rationale: A low apical pulse rate of 53 beats/min indicates bradycardia, which is a side effect of digoxin. Before administering digoxin, the nurse should always check the patient's pulse rate. If the apical pulse is below the facility's specified parameters (typically below 60 beats/min), the nurse should withhold the dose and notify the prescriber immediately. Bradycardia can be an indication of digoxin toxicity, which can be potentially life-threatening, so it is crucial to follow the protocol and seek further guidance before administering the medication.
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A client is prescribed Nitroglycerin sublingual tablets. Which of the following instructions should the nurse include during discharge teaching?
- A. Take the medication with food.
- B. Store the medication in a cool, dry place.
- C. Swallow the tablets whole.
- D. Take one tablet every 5 minutes up to three doses for chest pain.
Correct Answer: D
Rationale: During a chest pain episode, the client should take one nitroglycerin tablet sublingually every 5 minutes up to a total of three doses. If chest pain persists after three doses, emergency medical attention should be sought. Nitroglycerin should not be swallowed but allowed to dissolve under the tongue for rapid absorption. Storing the medication in a cool, dry place helps maintain its effectiveness.
A nurse is assessing a client who is receiving IV vancomycin. The nurse notes a flushing of the neck and tachycardia. Which of the following actions should the nurse take?
- A. Document that the client experienced an anaphylactic reaction to the medication.
- B. Change the IV infusion site.
- C. Decrease the infusion rate on the IV.
- D. Apply cold compresses to the neck area.
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
The nurse is preparing to give a potassium supplement. Which laboratory test should be checked before the patient receives a dose of potassium?
- A. Complete blood count
- B. Serum potassium level
- C. Serum sodium level
- D. Liver function studies
Correct Answer: B
Rationale: Before administering a potassium supplement to a patient, it is crucial to check the patient's serum potassium level. This is because if the serum potassium level is already elevated or within the high end of the normal range, giving additional potassium could lead to hyperkalemia, which can be life-threatening. Conversely, if the serum potassium level is low (hypokalemia), then administering potassium supplementation may be necessary to correct the deficiency. Monitoring the serum potassium level helps ensure safe and effective treatment with potassium supplements. It is a critical part of assessing the patient's electrolyte balance and overall health status.
Which statement is accurate concerning the use of aspirin (ASA) to treat pain?
- A. High doses are necessary (1 gram) to achieve anticoagulant effects.
- B. Enteric-coated capsules are available to reduce GI side effects.
- C. Increase consumption of herbs such as garlic and ginger to potentiate the anti-inflammatory effects.
- D. In low doses (325 mg), it significantly reduces inflammation.
Correct Answer: B
Rationale: Aspirin's use for pain involves anti-inflammatory and analgesic properties, but it risks GI irritation. Enteric-coated capsules minimize this by dissolving in the intestine, not the stomach, reducing bleeding risk—an accurate statement. High doses are true for anticoagulation, not pain relief, where lower doses suffice. Herbs like garlic and ginger increase bleeding risk, not inflammation relief, making it dangerous advice. Low doses (choice D, 325 mg) primarily prevent clotting, not significantly reduce inflammation, which requires higher doses. Choice B correctly reflects a practical measure to enhance aspirin's safety profile for pain management.
Restoration of blood flow results through the dissolution of clot by:
- A. fibrin
- B. plasmin
- C. thrombin
- D. prothrombin
Correct Answer: B
Rationale: Plasmin is an enzyme that is responsible for breaking down fibrin, a protein that forms blood clots. When an area of vessel needs to have its blood flow restored, such as after a clot has formed, plasmin is activated to dissolve the clot. By breaking down the fibrin mesh of the clot, plasmin helps restore normal blood flow in the affected vessel. Therefore, the restoration of blood flow results through the dissolution of clot by plasmin, making option B the correct answer.