A nurse is assessing a school-age child prior to administering digoxin. For which of the following findings should the nurse withhold the medication?
Urine output 25 mL/hr
Oxygen saturation 88%
Heart rate 64/min
Respiratory rate 18/min
The Correct Answer is C
A. Urine output 25 mL/hr – This is an adequate urine output for a school-age child and does not require withholding digoxin.
B. Oxygen saturation 88% – While low, this does not directly indicate digoxin toxicity or require withholding the medication. The underlying cause should be evaluated.
C. Heart rate 64/min – Digoxin can cause bradycardia, and a heart rate of 64/min is too low for a school-age child. Generally, digoxin should be withheld if the heart rate is below 70 bpm in children or below 90 bpm in infants.
D. Respiratory rate 18/min – This is within the normal range for a school-age child and does not warrant withholding digoxin.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["C","F","G"]
Explanation
Capillary refill 4 seconds (Cardiovascular) – Indicates poor perfusion and worsening dehydration.
Extremities cool (Integumentary) – Suggests impaired circulation, potential hypovolemia.
Reports no tears (Integumentary) – Sign of severe dehydration.
Lethargic (Neurologic) – Worsening mental status, could indicate hypovolemia or electrolyte imbalance.
Heart rate 112/min – Mildly elevated but not yet critical.
Respiratory rate 26/min – Within an acceptable range for a toddler.
Hyperactive bowel sounds – Expected with diarrhea.
Diaper area reddened – Needs care but not urgent
Correct Answer is C
Explanation
A. "Ask the child to hold their breath while the IV catheter is placed." Holding breath can increase anxiety and is not necessary for IV insertion. Instead, distraction techniques (e.g., deep breathing, counting) are more effective.
B. "Explain the procedure to the child in detail." Preschoolers have limited understanding of medical procedures. Instead, use simple, age-appropriate language and possibly a demonstration with a toy.
C. "Apply vapocoolant spray before the IV insertion." Vapocoolant spray or topical anesthetics (e.g., EMLA cream) help reduce pain and anxiety associated with IV insertion.
D. "Place the IV catheter on the dominant arm." IV placement is typically based on vein accessibility, not dominance. However, placing it on the non-dominant arm may be preferable to avoid interference with activities.
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