Nokea
The nurse is caring for a client receiving a cardiotonic drug. The client has edema. Which assessment would be most important?
- A. Auscultation of bowel sounds
- B. Measurement of intake and output
- C. Observation of respiratory rate
- D. Observation of pulse rate
Correct Answer: B
Rationale: Measurement of intake and output would be most important for the client with edema who is receiving a cardiotonic drug. Auscultation of bowel sounds, observation of respiratory rate, and observation of pulse rate are interventions not related to edema in the client.
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A client is prescribed droxin IV as a loading dose. The nurse would expect to administer the drug over which time frame?
- A. 30 seconds
- B. 2 minutes
- C. 5 minutes
- D. 30 minutes
Correct Answer: C
Rationale: When a cardiotonic drug is given IV, it is administered slowly (over at least 5 minutes), and the administration site is assessed for redness or infiltration.
A client is prescribed a cardiotonic medication. Which of the following preadministration assessments should the nurse perform on this client?
- A. Inspect joints for swelling.
- B. Check for jugular vein distention.
- C. Inspect skin for rash.
- D. Obtain blood glucose levels.
Correct Answer: B
Rationale: The nurse should check for jugular vein distention as part of the preadministration assessment for the client prescribed a cardiotonic. The nurse need not inspect joints for swelling, inspect skin for rash, or obtain blood glucose levels as these interventions will not provide necessary information with regard to administration of a cardiotonic.
A nurse caring for a client with atrial fibrillation who is started on digoxin therapy is required to monitor plasma drug levels. The nurse would report which level to the primary health care provider?
- A. 1.6 ng/ml
- B. 1.8 ng/ml
- C. 2.0 ng/ml
- D. 2.2 ng/ml
Correct Answer: D
Rationale: A plasma digoxin level of more than 2 ng/mL would require the nurse to report to the primary health care provider; therefore, plasma digitalis levels of 2.2 ng/mL indicate digoxin toxicity. The therapeutic levels range from 0.5 to 2 ng/mL.
When reviewing the medical record of a client who is prescribed a cardiotonic, which condition would lead the nurse to contact the primary health care provider because the drug is contraindicated for use? Select all that apply.
- A. Digitalis toxicity
- B. Hypertension
- C. Cardiac tamponade
- D. Hypotension
- E. Ventricular tachycardia
Correct Answer: A,C,E
Rationale: The cardiotonics are contraindicated in the presence of digitalis toxicity and in clients with known drug hypersensitivity, ventricular tachycardia, cardiac tamponade, restrictive cardiomyopathy, or AV block.
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.