A nurse is caring for an infant who has heart failure and a new prescription for digoxin.Which of the following findings should the nurse report to the provider?
Weight loss 0.25 kg (0.55 lb)
Vomiting twice in 4 hr
Respiratory rate 30/min
Heart rate 130/min
The Correct Answer is B
Choice A reason:
A weight loss of 0.25 kg (0.55 lb) may be within the range of normal fluctuation for an infant and may not necessarily warrant immediate reporting. However, it should be monitored closely.
Choice B reason:
Vomiting twice in 4 hours after receiving digoxin is a concerning finding. Digoxin has a narrow therapeutic range, and vomiting can lead to potential overdose. This should be reported to the provider for further evaluation.
Choice C reason:
A respiratory rate of 30/min may indicate increased work of breathing, which is a concern in an infant with heart failure. However, it is not specific to digoxin administration and may require
intervention but not immediate reporting.
Choice D reason:
A heart rate of 130/min is within the range of normal for an infant, especially one with heart failure. This finding is not specific to digoxin administration and may not warrant immediate reporting.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason:
Taping the wire to the palm of the hand can be uncomfortable for the child and may interfere with blood flow.
Choice B reason:
Warming the skin prior to probe placement is not a standard practice for pulse oximetry monitoring.
Choice C reason:
Applying the sensor to the index fingernail is not a recommended site for pulse oximetry monitoring in children.
Choice D reason:
Repositioning the probe every 2 hours helps to prevent skin breakdown and ensures accurate readings over time. This is a standard practice in pulse oximetry monitoring.
Correct Answer is B
Explanation
Choice A reason:
Cold compresses may exacerbate vaso-occlusion in a client with sickle cell anemia and are not recommended.
Choice B reason:
Maintaining bed rest can help reduce the risk of hypoxemia, as it minimizes energy expenditure and oxygen demand.
Choice C reason:
Increasing oral fluid intake is important for preventing vaso-occlusive crises, so decreasing fluid intake is not a recommended intervention.
Choice D reason:
Administering meperidine for fever is not a standard intervention for sickle cell anemia. Fever during a vaso-occlusive crisis should be evaluated and treated according to the underlying cause.
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