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":{"answers":"B"},"B":{"answers":"A,B,C"},"C":{"answers":"B,C"},"D":{"answers":"B"}}
Explanation
Bacterial Meningitis (Most Likely Diagnosis). Headache, nausea, irritability, lethargy, nuchal rigidity → Signs of meningeal irritation Petechiae → Possible meningococcal sepsis. Fever, chills, elevated WBC count (14,000/mm³) → Indicates an infection. Irregular respirations, agitation, capillary refill 4 seconds → Signs of worsening perfusion, possible sepsis
Hodgkin Lymphoma (Possible but Less Likely). Enlarged lymph nodes → Common in lymphoma but does not explain acute symptoms like fever, petechiae, or neurologic signs.
Acute Lymphoblastic Leukemia (ALL) (Possible but Less Likely). Petechiae → Possible due to thrombocytopenia, but child’s platelet count (350,000) is normal.. Enlarged lymph nodes → Can occur in leukemia but is not the primary concern given the acute symptoms.
Correct Answer is A
Explanation
A. "Capillary refill less than 2 seconds." A capillary refill time of less than 2 seconds indicates adequate hydration and perfusion, showing that the fluid replacement therapy has been effective.
B. "Potassium 5.6 mEq/L (3.4 to 4.7 mEq/L)." A potassium level of 5.6 mEq/L is elevated (hyperkalemia) and suggests an imbalance, which can result from inadequate kidney function or excessive potassium intake rather than effective rehydration.
C. "Voiding less than 1 mL/kg/hr." Decreased urine output is a sign of persistent dehydration or kidney dysfunction. Effective fluid therapy should restore normal urine output, typically greater than 1 mL/kg/hr in children.
D. "Tachycardia." Tachycardia is a sign of dehydration. If fluid replacement were effective, heart rate should normalize, not remain elevated.
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