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 A
Explanation
A. Mild hematuria. One of the hallmark signs of glomerulonephritis is hematuria (presence of blood in the urine). Mild hematuria is common and is often associated with glomerular injury, which allows red blood cells to pass through the glomerular filtration barrier.
B. Hyponatremia. Hyponatremia (low sodium levels) is not typically associated with glomerulonephritis. However, in severe cases of kidney dysfunction, fluid retention can lead to dilutional hyponatremia, but it is not a primary finding in glomerulonephritis.
C. Absent urine protein. Proteinuria (presence of protein in the urine) is a common finding in glomerulonephritis due to damage to the glomerular filtration barrier. It is typically present, though the amount may vary.
D. Decreased blood potassium. Hyperkalemia (increased potassium levels) is more commonly seen in acute kidney injury and glomerulonephritis due to decreased kidney function. Decreased potassium levels are not typical in this condition.
Correct Answer is D
Explanation
A. "Apply firm pressure to the wound base while removing the gauze dressing." Applying firm pressure can cause pain and damage the wound bed, delaying healing and increasing the risk of bleeding.
B. "Irrigate the wound with half-strength hydrogen peroxide while removing the gauze dressing." Hydrogen peroxide can damage healthy tissue and delay wound healing. It is not recommended for routine wound care.
C. "Continue to remove the gauze dressing by pulling it parallel to the skin." Removing a dry gauze dressing without moistening it can cause trauma to the wound bed, increasing pain and impeding healing.
D. "Saturate the gauze dressing with sterile saline solution prior to removing it." Moistening the dressing with sterile saline reduces trauma to the wound, prevents tissue damage, and minimizes pain. This method is preferred for atraumatic dressing removal.
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