The client is ordered to receive a cardiac glycoside. Which vital signs finding would make the nurse question administering this medication?
1. Blood pressure 119/66
2. Apical pulse 55 beats per minute
3. Temperature 99.4°F
4. Respirations 12 breaths per minute
Correct Answer: 2
Rationale 1: Cardiac glycosides are held if the pulse is less than 60 bpm.
Rationale 2: If the rate is lower than 60 beats per minute, the drug should not be given.
Rationale 3: Cardiac glycosides do not have an effect on temperature.
Rationale 4: Cardiac glycosides are held if the pulse is less than 60 bpm.
Global Rationale: If the rate is lower than 60 beats per minute, the drug should not be given. Blood pressure of 119/66, a temperature of 99.4°F, and respirations of 12 breaths per minutes would not cause the nurse to hold the dose of medication.
You might also like to view...
The nurse is reviewing the different types of laws. An example of administrative law that affects nursing is:
a. civil rights acts. b. substance abuse laws. c. nurse practice acts. d. negligence laws.
A nurse is actively involved in the political arena and is educating a colleague about becoming involved in the election process. The nurse knows that their teaching has been effective when a colleague states:
a. "Nurses are discouraged from becoming involved in politics.". b. "The election process has nothing to do with nursing.". c. "It is easy for a nurse to become involved in the election process.". d. "Political campaigns never need any help.".
A psychiatric patient is experiencing panic-level anxiety. The initial intervention of highest priority is:
a. provide for the patient's safety. b. reduce all environmental stimuli. c. respect the patient's personal space. d. encourage the patient to discuss the anxious feelings.
A high school student has learned that she cannot graduate. Her boyfriend will be attending a college out of state that she planned to also attend. She is admitted to a psychiatric unit after overdosing on Tylenol
Which is the correctly written priority nursing diagnosis for this client? A. Ineffective coping R/T situational crisis AEB powerlessness B. Anxiety R/T fear of failure C. Risk for self-directed violence R/T hopelessness D. Risk for low self-esteem R/T loss events AEB suicidal ideations