A nurse is caring for a child who ingested kerosene. Which of the following assessments is the nurse's priority?

Respiratory Rate

Bowel Sounds

Burns of the mouth

Visual Acuity

Answer and Explanation

The Correct Answer is A

A. Respiratory Rate – Correct. Hydrocarbon poisoning (such as kerosene ingestion) primarily affects the lungs and can lead to aspiration pneumonia, respiratory distress, and chemical pneumonitis.

B. Bowel Sounds – Incorrect. While gastrointestinal effects may occur, they are not the primary concern.

C. Burns of the mouth – Incorrect. Kerosene does not typically cause burns like caustic substances such as acids or alkalis.

D. Visual Acuity – Incorrect. Kerosene does not directly affect vision.

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Correct Answer is ["70"]

Explanation

The nurse should withhold digoxin if the child's apical heart rate is less than 70 beats per minute because digoxin slows the conduction of electrical signals in the heart and increases the force of cardiac contraction. While this helps to treat conditions like heart failure and arrhythmias, it can also lead to bradycardia. Administering digoxin when the heart rate is already too low increases the risk of adverse effects like severe bradycardia or even cardiac arrest.

A. Presence of dance sign B. Always seems full C. Projectile vomiting D. Excessive weight gain

Correct Answer is C

Explanation

A. Presence of Dance sign. – Incorrect. Dance sign (absence of bowel sounds in the right lower quadrant) is associated with intussusception, not pyloric stenosis.

B. Always seems full. – Incorrect. Babies with pyloric stenosis initially feed well but develop progressive vomiting and hunger after feeds.

C. Projectile vomiting. – Correct. Pyloric stenosis causes forceful, non-bilious projectile vomiting due to gastric outlet obstruction.

D. Excessive weight gain. – Incorrect. Infants with pyloric stenosis typically experience weight loss or poor weight gain due to vomiting.

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A nurse is caring for a child who ingested kerosene. Which of the following assessments is the nurse's priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to administer digoxin to a 12 year-old child. Prior to administering the dose. the nurse measures the apical heart rate. The nurse should withhold the dose if the child's apical heart rate is less than what rate?

Correct Answer is ["70"]

Explanation

A nurse is caring for a newborn who may have pyloric stenosis. Which of the following manifestations should the nurse expect?

Correct Answer is C

Explanation

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