- The nurse assesses the heart rate prior to administering digoxin. Which finding should concern the nurse?
a. Less than 60 bpm
b. Greater than 100 bpm
Digoxin is given to the patient to treat heart failure as well as arrhythmias. Digoxin lowers the heart rate so if the heart rate is lower than 60 bpm, the nurse should withhold the medication and notify the physician.
- The nurse should administer glucose to the patient for which of the following?
Glucose should be administered if the patient is experiencing hypoglycemia. Insulin is given if the patient is experiencing hyperglycemia.
- A patient is receiving meperidine (Demerol). The nurse should be concerned about which finding?
a. Respiratory rate of 22 breaths/min
b. Respiratory rate of 12 breaths/min
Meperidine (Demerol) can cause respiratory depression. The nurse must monitor the patient for bradycardia.
- A patient with kidney failure is receiving metoprolol 25 mg. The nurse should be concerned about which finding?
a. Blood pressure 80/60 mm Hg
b. Blood pressure 150/77 mm Hg
Metoprolol can cause hypotension so the nurse must monitor the patient for a decrease in blood pressure. A patient with kidney failure would have difficulty regulating blood pressure so an increased blood pressure would be a normal finding, especially prior to hemodialysis treatments.
- The nurse is assessing the patient’s arteriovenous (AV) fistula. Which of the following is a normal finding?
a. Negative bruits and thrills
b. Positive bruits and thrills
Positive bruits and thrills are normal findings when assessing the patient’s arteriovenous (AV) fistula. The nurse would not be able to cannulate the access site without the positive bruits and thrills. The physician must be notified.
Congratulations on making it this far! Even if you did not get all of the answers correct, you took the time to read the rationales and now you have a better understanding of how to eliminate the opposite answer. You are able to select the answer that is the correct answer in preparation for the NCLEX.
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