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)

Answer and Explanation

The Correct Answer is A

Vomiting can lead to decreased absorption of digoxin, potentially resulting in subtherapeutic levels and inadequate therapeutic effect. The plan of care should be revised to address the vomiting and consider alternative routes of administration or doses.

A digoxin level within the therapeutic range indicates adequate drug absorption and effectiveness.

An apical pulse of 100/min is within the expected range for toddlers and does not necessarily require a revision of the plan of care related to digoxin therapy.

A potassium level within the normal range is desirable and does not necessarily require a revision of the plan of care related to digoxin therapy.

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Correct Answer is C

Explanation

A. Tying restraints to the side rails poses a risk of injury to the child and is not a recommended practice.
B. Renewing the prescription for restraints every 48 hours is important, but it does not directly address the proper application of restraints.
C. Securing restraints with a quick-release knot allows for quick removal in case of emergency and is the correct method for applying restraints.
D. Assessing the child every 4 hours while in restraints is important, but it does not address the proper application of restraints.

A. Infuse each unit of blood within 4 hr. B. Infuse dextrose 5% in water during the infusion of packed RBCs. C. Store the second unit of blood at room temperature for up to 2 hr. D. Administer RBCs using non-filtered IV tubing.

Correct Answer is A

Explanation

A. Infusing each unit of blood within 4 hours is a standard practice to minimize the risk of bacterial contamination and ensure the effectiveness of the transfusion. This intervention helps maintain the integrity and safety of the blood product.
B. Infusing dextrose 5% in water during the infusion of packed RBCs is unnecessary and not recommended as it can lead to hemolysis of the blood cells and potential adverse reactions.
C. Storing the second unit of blood at room temperature for up to 2 hours is incorrect practice. Blood products should be stored according to specific guidelines to maintain their integrity and safety.
D. Administering RBCs using non-filtered IV tubing is inappropriate as it can lead to the infusion of clots or debris, which can be harmful to the patient. The use of filtered IV tubing is recommended to ensure the safety of the transfusion.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

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