Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
Prior to giving digoxin, the practical nurse (PN) assesses that a 2-month-old infant's heart rate is 120 beats/minute. Based on this, what action should the PN take?
A. Administer the medication and alert the charge nurse
This is not the action that the PN should take prior to giving digoxin to a 2-month-old infant whose heart rate is 120 beats/minute. Alerting the charge nurse is not necessary, as the heart rate is normal and does not indicate a problem with the medication or the client's condition. The PN should administer the medication as prescribed and document the heart rate and any other relevant findings.
B. Hold the medication and document cardiac assessment
This is not the action that the PN should take prior to giving digoxin to a 2-month-old infant whose heart rate is 120 beats/minute. Holding the medication is not appropriate, as the heart rate is normal and does not indicate a contraindication or a risk of adverse effects from the medication. The PN should administer the medication as prescribed and document the heart rate and any other relevant findings.
C. Administer the medication and document the heart rate
This is the action that the PN should take prior to giving digoxin to a 2-month-old infant whose heart rate is 120 beats/minute. Digoxin is a cardiac glycoside that is used to treat heart failure and arrhythmias. It has a narrow therapeutic range and can cause serious side effects such as bradycardia, hypotension, and toxicity. Therefore, it is important to monitor the client's vital signs before and after administering the medication. A normal heart rate for a 2-month-old infant is 100–190 beats/minute, so 120 beats/minute is within the normal range and does not indicate a need to hold the medication. The PN should administer the medication as prescribed and document the heart rate and any other relevant findings.
D. Hold the medication and recheck the heart rate in 1 hour
This is not the action that the PN should take prior to giving digoxin to a 2-month-old infant whose heart rate is 120 beats/minute. Holding the medication and rechecking the heart rate in 1 hour is not necessary, as the heart rate is normal and does not indicate a need for further evaluation or intervention. The PN should administer the medication as prescribed and document the heart rate and any other relevant findings.
This question is an excerpt from Nurse Dive's nursing test bank - HESI PN Exit 2023 II Proctored Exam. Take the full exam now
Full Explanation
The correct answer and explanation is:
c) Administer the medication and document the heart rate.
This is the action that the PN should take prior to giving digoxin to a 2-month-old infant whose heart rate is 120 beats/minute. Digoxin is a cardiac glycoside that is used to treat heart failure and arrhythmias. It has a narrow therapeutic range and can cause serious side effects such as bradycardia, hypotension, and toxicity. Therefore, it is important to monitor the client's vital signs before and after administering the medication. A normal heart rate for a 2-month-old infant is 100–190 beats/minute, so 120 beats/minute is within the normal range and does not indicate a need to hold the medication. The PN should administer the medication as prescribed and document the heart rate and any other relevant findings.
a) Administer the medication and alert the charge nurse.
This is not the action that the PN should take prior to giving digoxin to a 2-month-old infant whose heart rate is 120 beats/minute. Alerting the charge nurse is not necessary, as the heart rate is normal and does not indicate a problem with the medication or the client's condition. The PN should administer the medication as prescribed and document the heart rate and any other relevant findings.
b) Hold the medication and document cardiac assessment.
This is not the action that the PN should take prior to giving digoxin to a 2-month-old infant whose heart rate is 120 beats/minute. Holding the medication is not appropriate, as the heart rate is normal and does not indicate a contraindication or a risk of adverse effects from the medication. The PN should administer the medication as prescribed and document the heart rate and any other relevant findings.
d) Hold the medication and recheck the heart rate in 1 hour.
This is not the action that the PN should take prior to giving digoxin to a 2-month-old infant whose heart rate is 120 beats/minute. Holding the medication and rechecking the heart rate in 1 hour is not necessary, as the heart rate is normal and does not indicate a need for further evaluation or intervention. The PN should administer the medication as prescribed and document the heart rate and any other relevant findings.
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Similar Questions
The practical nurse (PN) believes that a prescription for a child is incorrect because the dosage prescribed is the usual adult dosage. Which action should the PN take?
A. Tell the pharmacy to send an accurate child's dosage
This is not the action that the PN should take if they believe that a prescription for a child is incorrect because the dosage prescribed is the usual adult dosage. Telling the pharmacy to send an accurate child's dosage is not appropriate, as it may cause confusion, delay, or conflict with the healthcare provider's orders. The PN should not assume that they know the correct dosage for the child without consulting with the healthcare provider.
B. Ask another nurse if adult dosages are ever given to children
This is not the action that the PN should take if they believe that a prescription for a child is incorrect because the dosage prescribed is the usual adult dosage. Asking another nurse if adult dosages are ever given to children is not helpful, as it may not provide accurate or reliable information. The PN should not rely on another nurse's opinion or experience without verifying it with the healthcare provider.
C. Call the healthcare provider and clarify the prescription
This is the action that the PN should take if they believe that a prescription for a child is incorrect because the dosage prescribed is the usual adult dosage. Calling the healthcare provider and clarifying the prescription is the safest and most effective way to prevent medication errors and ensure the child's safety. The PN should not administer the medication until they are sure that it is correct and appropriate for the child.
D. Request verification of the prescription by the charge nurse
This is not the action that the PN should take if they believe that a prescription for a child is incorrect because the dosage prescribed is the usual adult dosage. Requesting verification of the prescription by the charge nurse is not necessary, as it may waste time and resources. The PN should be able to communicate directly with the healthcare provider and clarify any doubts or concerns about the prescription.
Full Explanation
The correct answer and explanation is:
c) Call the healthcare provider and clarify the prescription.
This is the action that the PN should take if they believe that a prescription for a child is incorrect because the dosage prescribed is the usual adult dosage. Calling the healthcare provider and clarifying the prescription is the safest and most effective way to prevent medication errors and ensure the child's safety.
The PN should not administer the medication until they are sure that it is correct and appropriate for the child.
a) Tell the pharmacy to send an accurate child's dosage.
This is not the action that the PN should take if they believe that a prescription for a child is incorrect because the dosage prescribed is the usual adult dosage. Telling the pharmacy to send an accurate child's dosage is not appropriate, as it may cause confusion, delay, or conflict with the healthcare provider's orders. The PN should not assume that they know the correct dosage for the child without consulting with the healthcare provider.
b) Ask another nurse if adult dosages are ever given to children.
This is not the action that the PN should take if they believe that a prescription for a child is incorrect because the dosage prescribed is the usual adult dosage. Asking another nurse if adult dosages are ever given to children is not helpful, as it may not provide accurate or reliable information. The PN should not rely on another nurse's opinion or experience without verifying it with the healthcare provider.
d) Request verification of the prescription by the charge nurse.
This is not the action that the PN should take if they believe that a prescription for a child is incorrect because the dosage prescribed is the usual adult dosage. Requesting verification of the prescription by the charge nurse is not necessary, as it may waste time and resources. The PN should be able to communicate directly with the healthcare provider and clarify any doubts or concerns about the prescription.
A dentist informs the practical nurse (PN) that she has a family history of cancer and has increased the amount of dairy products in her diet to reduce the risk of gingivitis. How should the PN respond?
A. Suggest an increase in fruits and vegetables is more beneficial
In this scenario, the dentist is increasing the amount of dairy products in her diet with the aim of reducing the risk of gingivitis due to her family history of cancer. However, the practical nurse (PN) should respond by suggesting that an increase in fruits and vegetables would be more beneficial. Fruits and vegetables are rich in essential vitamins, minerals, and antioxidants, which can help support overall oral health and reduce the risk of gingivitis. They provide a wide range of nutrients that are important for maintaining healthy gums and teeth. While dairy products can contribute to overall dental health due to their calcium content, they should not be solely relied upon as the primary means of preventing gingivitis or reducing the risk of cancer. A well- rounded and balanced diet, including plenty of fruits and vegetables, is essential for optimal oral health.
B. Encourage the client to get plenty of exercise as well as the dietary change
Encouraging exercise (option b) is generally beneficial for overall health, but it does not specifically address gingivitis.
C. Remind the client to make sure the dairy products are fortified with Vitamin D
Reminding the client to ensure dairy products are fortified with vitamin D (option c) is not necessary in this context, as the focus is on preventing gingivitis rather than addressing vitamin D deficiency.
D. Provide writen information about the warning signs of cancer
Providing writen information about the warning signs of cancer (option d) is not directly relevant to the dentist's current situation and concern about gingivitis.
Full Explanation
a) Suggest an increase in fruits and vegetables is more beneficial.
In this scenario, the dentist is increasing the amount of dairy products in her diet with the aim of reducing the risk of gingivitis due to her family history of cancer. However, the practical nurse (PN) should respond by suggesting that an increase in fruits and vegetables would be more beneficial.
Fruits and vegetables are rich in essential vitamins, minerals, and antioxidants, which can help support overall oral health and reduce the risk of gingivitis. They provide a wide range of nutrients that are important for maintaining healthy gums and teeth.
While dairy products can contribute to overall dental health due to their calcium content, they should not be solely relied upon as the primary means of preventing gingivitis or reducing the risk of cancer. A well- rounded and balanced diet, including plenty of fruits and vegetables, is essential for optimal oral health.
Options b, c, and d are not directly related to the dentist's concern about gingivitis and the increased consumption of dairy products. Encouraging exercise (option b) is generally beneficial for overall health, but it does not specifically address gingivitis. Reminding the client to ensure dairy products are fortified with vitamin D (option c) is not necessary in this context, as the focus is on preventing gingivitis rather than addressing vitamin D deficiency. Providing writen information about the warning signs of cancer (option d) is not directly relevant to the dentist's current situation and concern about gingivitis.
A male client who has just been told he has cancer asks the practical nurse (PN) to leave his room so he can be alone.
Which action should the PN implement?
A. Consult with the charge nurse about implementing suicide precautions
This is not the action that the PN should implement for a male client who has just been told he has cancer and asks to be left alone. Consulting with the charge nurse about implementing suicide precautions is premature and unnecessary, as there is no evidence that the client is suicidal or at risk of harming himself. The client's request to be alone is a normal and understandable reaction to a stressful and life-changing situation, not a sign of suicidal ideation or intent.
B. Sit quietly in the client's room until the client is ready to verbalize his feelings
This is not the action that the PN should implement for a male client who has just been told he has cancer and asks to be left alone. Sitting quietly in the client's room until he is ready to verbalize his feelings is intrusive and disrespectful, as it goes against the client's wishes and may make him feel uncomfortable or pressured. The PN should not impose their presence or expectations on the client, but should honor his request and give him some privacy.
C. Notify a member of the client's family of the need to come stay with the client
This is not the action that the PN should implement for a male client who has just been told he has cancer and asks to be left alone. Notifying a member of the client's family of the need to come stay with him is inappropriate and unethical, as it violates the client's confidentiality and autonomy. The PN should not share the client's diagnosis or condition with anyone without his consent, nor should they assume that he wants or needs his family's support at this time. The PN should respect the client's right to decide who he wants to involve in his care and when.
D. Leave the room after offering to return to the client's room at a later time
This is the action that the PN should implement for a male client who has just been told he has cancer and asks to be left alone. Leaving the room after offering to return later respects the client's autonomy and privacy, while also showing empathy and availability. The client may need some time and space to process the diagnosis and cope with his emotions. The PN should not force the client to talk or stay with him if he does not want to, but should also not abandon him or ignore his needs.
Full Explanation
d) Leave the room after offering to return to the client's room at a later time.
This is the action that the PN should implement for a male client who has just been told he has cancer and asks to be left alone. Leaving the room after offering to return later respects the client's autonomy and privacy, while also showing empathy and availability. The client may need some time and space to process the diagnosis and cope with his emotions. The PN should not force the client to talk or stay with him if he does not want to, but should also not abandon him or ignore his needs.
a) Consult with the charge nurse about implementing suicide precautions.
This is not the action that the PN should implement for a male client who has just been told he has cancer and asks to be left alone. Consulting with the charge nurse about implementing suicide precautions is premature and unnecessary, as there is no evidence that the client is suicidal or at risk of harming himself. The client's request to be alone is a normal and understandable reaction to a stressful and life-changing situation, not a sign of suicidal ideation or intent.
b) Sit quietly in the client's room until the client is ready to verbalize his feelings.
This is not the action that the PN should implement for a male client who has just been told he has cancer and asks to be left alone. Sitting quietly in the client's room until he is ready to verbalize his feelings is intrusive and disrespectful, as it goes against the client's wishes and may make him feel uncomfortable or pressured. The PN should not impose their presence or expectations on the client, but should honor his request and give him some privacy.
c) Notify a member of the client's family of the need to come stay with the client.
This is not the action that the PN should implement for a male client who has just been told he has cancer and asks to be left alone. Notifying a member of the client's family of the need to come stay with him is inappropriate and unethical, as it violates the client's confidentiality and autonomy. The PN should not share the client's diagnosis or condition with anyone without his consent, nor should they assume that he wants or needs his family's support at this time. The PN should respect the client's right to decide who he wants to involve in his care and when.