A nurse is caring for a 2-month-old infant who has heart failure and is receiving furosemide.
Which of the following findings is the nurse's priority?
Negative doll's eye reflex
Sunken anterior fontanel
Potassium 5.1 mEq/L
Heart rate 162/min
The Correct Answer is D
A. Negative doll's eye reflex (also known as oculocephalic reflex) is a normal finding in infants. It is a reflexive movement of the eyes in the opposite direction of the head
movement.
B. A sunken anterior fontanel can indicate dehydration, which is a concern. However, in a 2-month-old with heart failure, a high heart rate (tachycardia) may indicate worsening of the heart failure and needs to be addressed promptly.
C. A potassium level of 5.1 mEq/L is within the normal range for infants. While electrolyte balance is important, it is not the priority in this situation.
D. This is the correct answer. A heart rate of 162/min in a 2-month-old infant with heart failure is elevated and requires immediate attention. It may indicate worsening heart
failure or an adverse reaction to the medication (furosemide) being administered. The nurse should assess the infant's condition, notify the healthcare provider, and intervene as necessary.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A.While an elevated cholesterol level is a concern in diabetes, it is not the priority in this case. The elevated HbA1c level indicates a more pressing issue that requires immediate attention.
B. The correct answer is B. HbA1c 11.5%. HbA1c is a measure of the average blood glucose level over the past 2 to 3 months. A high HbA1c indicates poor glycemic control and increased risk of complications from diabetes. The nurse's priority is to address the factors that are contributing to the high HbA1c and provide education and support to improve the adolescent's self-management.
C. Glycosuria, while important to monitor, is a common finding in uncontrolled diabetes.
It indicates elevated blood glucose levels and may require adjustments in the treatment plan. However, it is not as critical as addressing the elevated HbA1c level.
D. A preprandial blood glucose level of 124 mg/dL is within a reasonable range for an adolescent with diabetes. It is important to monitor blood glucose levels, but the elevated HbA1c level takes precedence in this situation.
Correct Answer is A
Explanation
A. This statement indicates understanding. Giving water after administering digoxin helps ensure that the medication is swallowed and reaches the stomach, which is important for proper absorption.
B. Giving digoxin with foods high in fiber is not a specific instruction for administering this medication. It is important to follow the healthcare provider's specific dosing
instructions.
C. If a child vomits after taking digoxin, the parent should not give another dose. They should wait until the next scheduled dose. Double dosing can lead to overdose.
D. Mixing digoxin with juice is not recommended, as it may affect the absorption of the medication. It is best to give digoxin with a small amount of water.
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