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 vomited 2 times in the last hour
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)
The Correct Answer is A
A. Vomiting is a sign of potential digoxin toxicity, and the nurse should revise the plan of care for this toddler.
B. This digoxin level is within the therapeutic range.
C. An apical pulse of 100/min could be normal for a toddler, but it should be monitored closely in the context of digoxin therapy.
D. This potassium level is within the normal range.
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Related Questions
Correct Answer is D
Explanation
A. Offering a prize for not crying may inadvertently reinforce crying as an expectation.
B. This statement is not accurate because the medicine might not fix the problem or make the child feel better immediately.
C. Assuring the child that they will only feel a little stick is not honest because the injection might hurt more than a little stick, and lying to the child can damage the trust between the nurse and the child.
D. Allowing the child to choose the injection site allows the child to have some control and autonomy over the situation, which can reduce anxiety and fear.
Correct Answer is C
Explanation
A. Asking the child's parent to leave the room during the procedure may increase the child's anxiety and make the procedure more traumatic.
B. Performing the procedure in the unit's playroom may not provide the necessary equipment and sterile environment required for a venipuncture.
C. Applying a topical anesthetic cream helps reduce pain and discomfort during the venipuncture, promoting atraumatic care.
D. Explaining the procedure in detail to the child 3 hours prior to the procedure may increase anxiety and anticipation, making the procedure more traumatic.
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