A long-term care nurse about to give a daily dose of digoxin ...

[shenderson6]

A long-term care nurse about to give a daily dose of digoxin (Lanoxin) is told that a serum digoxin level drawn earlier in the day measured 2.7 ng/mL. The nurse should take which of the following actions first?
 
  1. Administer the daily dose of the medication.
  2. Report the finding to the health care provider.
  3. Record the normal value on the intershift report sheet.
  4. Gather data from the client related to signs of toxicity.

Question 2

The nurse is caring for a child who was burned in a house fire. The nurse develops a plan of care for monitoring the child during the treatment for burn shock.
 
  The nurse identifies which of the following assessments as providing the most accurate guide to determine the adequacy of fluid resuscitation? 1. Heart rate
  2. Lung sounds
  3. Level of consciousness
  4. Amount of edema at the site of the burn injury

[emilymalinowski12]

Answer to Question 1

4

Rationale: The normal therapeutic range for digoxin is 0.5 to 2.0 ng/mL. A value of 2.7 ng/mL exceeds the therapeutic range and could be toxic to the client. The nurse should gather data about signs of digoxin toxicity and then notify the health care provider. Record the normal value on the intershift report sheet is incorrect because the value is high, not normal, and dismisses the subject at hand. Administer the daily dose of the medication is incorrect because the next dose should not be administered automatically.

Answer to Question 2

3

Rationale: The sensorium, or level of consciousness, is an important guide to the adequacy of fluid resuscitation. The burn injury itself does not affect the sensorium, so the child should be alert and oriented. Any alteration in sensorium should be evaluated further. A neurological as-sessment would determine the level of consciousness in the child. Heart rate, lung sounds, and amount of edema at the site of the burn injury, although important in the assessment of the child with a burn injury, would not provide an accurate assessment of the adequacy of fluid re-suscitation.

[shenderson6]

Gracias!

[isabelt_18]

Excellent