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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Packed red blood cells should typically be infused within 4 hours to reduce the risk of bacterial contamination and ensure potency.
B. Dextrose 5% in water is not typically infused with packed RBCs; the focus is on administering blood products as prescribed.
C. Blood products are typically stored under controlled conditions and transfused promptly after verification and compatibility checks.
D. Filtered IV tubing is often used for blood transfusions to minimize the risk of air embolism and particle infusion, but it's not the primary intervention listed for the scenario.
Correct Answer is B
Explanation
A. The nurse should not encourage flexion and extension of the neck, as this could cause further injury or damage to the spinal cord.
B. The nurse should reposition the client using a turning sheet to prevent skin breakdown and maintain alignment of the spine.
C. The nurse should assess the pin sites for infection at least once a day, not every other day.
D. The nurse should not tighten the screws on the halo device, as this could cause pressure ulcers or nerve damage. Only a provider can adjust the screws on the halo device.
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