Nokea
The client who is to receive a scheduled dose of digoxin has an irregular apical pulse at 92 bpm and a serum potassium of 3.9 mEq/L. Which nursing documentation reflects the most appropriate action?
- A. Serum potassium level WNL. Digoxin given for rapid apical pulse.
- B. Digoxin withheld because the client's apical heart rate is irregular.
- C. Digoxin withheld to prevent toxicity due to the low potassium level.
- D. HCP informed of irregular heart rate and low serum potassium level.
Correct Answer: A
Rationale: A: A normal serum potassium level is 3.5 to 5.0 mEq/L. Digoxin (Lanoxin), a cardiac glycoside, slows and strengthens the heart. It is used for rate control in clients with atrial fibrillation, which often produces an irregular rhythm. B: Dysrhythmias can occur if digoxin is given when the serum potassium level is low, but the serum potassium level is WNL. Digoxin is used for rate control and would not be withheld due to an irregular HR. C: Although it is important to monitor for digoxin toxicity, the serum potassium level is WNL. D: Withholding digoxin and notifying the HCP are unnecessary; the serum potassium is WNL.
You may also like to solve these questions
The client is being discharged with a prescription for an inhaled glucocorticoid for asthma. Which of the following statements indicates additional education is needed prior to discharge?
- A. I will hold my breath for 10 seconds after each puff.
- B. I will wait five minutes after taking this medication and then gargle water.
- C. I will wait at least one minute in between each puff.
- D. I will take this medication daily even if I am not having symptoms.
Correct Answer: B
Rationale: The client should gargle and spit water immediately after taking an inhaled glucocorticoid to remove residue of the medication, which can lead to thrush.
The nurse is preparing to administer IV fluids to the 13-kg child who has dehydration. The daily IV fluid requirement is to administer 1000 mL / 50 mL/kg over 10 kg. How many milliliters per hour should the nurse calculate to administer the IV therapy correctly?
Correct Answer: 48
Rationale: This child weighs 13 kg; the daily requirement is 1000 mL + (50 mL x 3) = 1150 mL/24 hr. The hourly rate is 1150 mL/ 24 hr = 47.9167 mL/hr, rounded to 48 mL/hr.
The nurse is caring for a 4-year-old client. What is the most appropriate pain scale for the nurse to use during the assessment?
- A. McGill Pain Scale
- B. FLACC Pain Scale
- C. CRIES Pain Scale
- D. Wong-Baker Pain Scale
Correct Answer: D
Rationale: The Wong-Baker Pain Scale uses faces to identify the level of pain. Children over the age of 3 should use this scale to articulate their subjective feeling of pain as opposed to objective measures using the CRIES or FLACC Pain Scales. The McGill Pain Scale uses many words to characterize pain and is more appropriate for adult clients.
The 16-year-old, hospitalized for barbiturate overdose, is receiving low-dose dopamine at 1 mcg/kg/min. Which finding in the client's medical record illustrated should prompt the nurse to conclude that dopamine is effective?
- A. Decrease in PACs
- B. Increase in urine output
- C. Decrease in pulse pressure
- D. Increase in the diastolic BP
Correct Answer: B
Rationale: A: Dopamine (Intropin) will have no effect on decreasing the incidence of PACs. B: Low-dose dopamine, 0.5-2.0 mcg/kg/min, acts on dopaminergic receptor sites along afferent arterioles in the glomerulus, dilates the renal vasculature, and improves urine output. C: Positive inotropic effects of dopamine include an increase in systolic BP with an increase in pulse pressure. D: Positive inotropic effects of dopamine include an increase in systolic BP with little or no effect on DBP.
The client, admitted to the ED, is prescribed to receive 0.5 mg epinephrine subcutaneously for treatment of a severe asthma attack. The medication for injection is supplied in a vial that contains 5 mg/mL. How many milliliters of epinephrine should the nurse administer?
Correct Answer: 0.1
Rationale: Use a proportion to determine the amount in milliliters; then multiply the extremes (outside values) and the means (inside values) and solve for X. 5 mg: 1 mL :: 0.5 mg: X mL; 5X = 0.5 mL; X = 0.1 mL; the nurse should administer 0.1 mL of epinephrine (Adrenalin).