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
A dietitian should be consulted for a newly admitted child to assess and plan for the child’s nutritional needs, especially if the child has specific dietary requirements or is at risk for malnutrition.
Choice B rationale
An occupational therapist may be involved later in the child’s care, but they are not typically the first referral for a newly admitted child.
Choice C rationale
A physical therapist may be involved later in the child’s care, but they are not typically the first referral for a newly admitted child.
Choice D rationale
A speech-language pathologist may be involved later in the child’s care, but they are not typically the first referral for a newly admitted child.
Correct Answer is B
Explanation
The correct answer is Choice B.
Choice A rationale
Reinforcing the dressing may be necessary, but controlling bleeding is the immediate priority. Applying pressure just above the insertion site is the first step to control bleeding and prevent further blood loss.
Choice B rationale
Applying pressure just above the insertion site is the first step to control bleeding and prevent further blood loss. This action helps to stop the bleeding and stabilize the patient.
Choice C rationale
Obtaining vital signs is important, but it can wait momentarily until the bleeding is under control. The immediate priority is to stop the bleeding.
Choice D rationale
Monitoring the pulse distal to the insertion site is important, but controlling bleeding takes precedence. Once the bleeding is controlled, the nurse can then monitor the pulse. .
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