A nurse is caring for a group of toddlers receiving digoxin therapy.
For which of the following toddlers should the nurse revise the plan of care?
A toddler who has a digoxin level of 1.2 ng/mL (0.8 to 2 ng/mL).
A toddler who has an apical pulse of 100/min.
A toddler who has a potassium level of 4.0 mEq/L (3.4 to 4.7 mEq/L).
A toddler who has vomited 2 times in the last hour.
The Correct Answer is D
The correct answer is Choice D.
Choice A rationale
A digoxin level of 1.2 ng/mL is within the therapeutic range (0.8 to 2 ng/mL) for toddlers receiving digoxin therapy. This level does not require a revision of the plan of care.
Choice B rationale
An apical pulse of 100/min is within the normal range for toddlers. Digoxin therapy requires monitoring of the heart rate, but this pulse rate does not necessitate a change in the plan of care.
Choice C rationale
A potassium level of 4.0 mEq/L is within the normal range (3.4 to 4.7 mEq/L) for toddlers. This electrolyte level does not require a revision of the plan of care.
Choice D rationale
Vomiting is a potential sign of digoxin toxicity. A toddler who has vomited 2 times in the last hour may be experiencing digoxin toxicity, and the plan of care should be revised to address this issue. .
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct answer is Choice A.
Choice A rationale
Ensuring that all patients are moved out of harm’s way is the first priority in a nursing home fire situation. This action aligns with the principles of the ABCs of nursing prioritization, where ensuring safety and preventing harm is paramount.
Choice B rationale
Removing all flammable materials from the area and extinguishing the fire is important, but it comes after ensuring the safety of the patients. The primary focus should be on patient safety.
Choice C rationale
Reporting to the area of the fire and taking measures to extinguish and/or contain it, if possible, is a secondary action. The immediate priority is to ensure the safety of the patients.
Choice D rationale
Evacuating all patients from the building immediately is not always feasible or safe. The priority is to move patients out of immediate harm’s way and then proceed with further evacuation if necessary.
Correct Answer is B
Explanation
The correct answer is Choice B.
Choice A rationale
Engaging in parallel play is a normal developmental behavior for an 18-month-old toddler. It indicates that the child is beginning to interact with peers, even if they are not yet playing cooperatively.
Choice B rationale
Walking with assistance at 18 months may indicate a potential developmental delay. By this age, most toddlers should be able to walk independently. If a child is still requiring assistance, it may warrant further evaluation.
Choice C rationale
Speaking at least 10 words is within the expected developmental range for an 18-month-old. This milestone indicates that the child is developing language skills appropriately.
Choice D rationale
Building a tower of 3 blocks is a typical developmental milestone for an 18-month-old. It demonstrates fine motor skills and cognitive development. .
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