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:
A temperature of 37.7° C (99.9° F) is slightly elevated but not a cause for immediate concern after immunization. It can be a normal response.
Choice B reason:
Redness at the injection site is a common and expected reaction after immunization. It does not require immediate intervention.
Choice C reason:
Prolonged crying can occur after immunization, but it is not a priority over a potential allergic reaction indicated by hives.
Choice D reason:
Hives on the child's neck indicate a potential allergic reaction to the immunization. This is a priority finding and requires immediate attention from the nurse.
Correct Answer is ["C","D","E"]
Explanation
Choice A reason:
Tinnitus - Tinnitus (ringing in the ears) is not typically associated with bacterial meningitis. The focus is on central nervous system symptoms and signs of meningeal irritation.
Choice B reason:
Negative Kernig sign - This is a classic sign of meningeal irritation. In bacterial meningitis, the Kernig sign will be positive, indicating resistance and pain upon extension of the knee after flexing the hip.
Choice C reason:
Vomiting - Nausea and vomiting are common symptoms of bacterial meningitis. They are caused by increased intracranial pressure and meningeal irritation.
Choice D reason:
Headache - Headache is a common symptom of bacterial meningitis, often severe and accompanied by other signs of meningeal irritation.
Choice E reason:
Seizures - Seizures can occur in bacterial meningitis due to the inflammation and irritation of the brain.
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