A nurse is caring for an infant who has heart failure and vomited following administration of digoxin. Which of the following actions should the nurse take?
Administer the next dose as prescribed
Mix the medication with 8 oz of formula
Give an antiemetic.
Increase fluid intake.
The Correct Answer is A
A. Vomiting after administering digoxin could be a sign of digoxin toxicity or intolerance. Before giving another dose, it is crucial to assess the infant’s condition, check for signs of digoxin toxicity, and consult with the healthcare provider. Administering the next dose without addressing the underlying issue could worsen the situation.
B. Mixing digoxin with a large volume of formula is not recommended. Digoxin should be administered in precise doses, and diluting it in such a large volume could lead to inaccuracies in dosing. Furthermore, mixing medication with formula does not address the issue of vomiting or potential toxicity.
C. While giving an antiemetic might seem like a solution to vomiting, it does not address the root cause of the vomiting, which could be related to digoxin toxicity or another issue. The first step should be to
assess the situation and determine if the vomiting is related to digoxin levels, and then consult with the healthcare provider. They may recommend appropriate interventions based on the infant’s condition.
D. Increasing fluid intake might be beneficial to prevent dehydration from vomiting, but it does not address the potential underlying cause of the vomiting, which could be related to digoxin toxicity. It is important to focus on the underlying cause and consult with the healthcare provider to determine the appropriate action. Managing fluid intake alone does not resolve the issue with digoxin or its side effects.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Phototherapy can increase a newborn's body temperature. Frequent monitoring is essential to prevent overheating.
B. Mittens may be used but their use is not directly related to phototherapy.
C. Applying lotion can interfere with the effectiveness of phototherapy. The newborn's skin should be kept clean and dry.
D. The newborn's eyes should be checked more frequently, typically every 4 hours, to monitor for any irritation or inflammation caused by the light.
Correct Answer is A
Explanation
A. Shakiness is a common symptom of hypoglycemia. When blood glucose levels drop, the body may react with symptoms like trembling or shaking. This is because low blood sugar levels can trigger the release of adrenaline, leading to physical symptoms such as shakiness.
B. While decreased appetite can occur in various conditions, it is not a primary or specific manifestation of hypoglycemia. Typically, hypoglycemia causes symptoms related to the body’s response to low glucose levels, such as shakiness, sweating, or confusion, rather than a decrease in appetite.
C. Thirst is more commonly associated with hyperglycemia (high blood glucose levels), not hypoglycemia. When blood glucose levels are high, the body tries to get rid of the excess sugar through increased urination, leading to dehydration and increased thirst. This is not a typical sign of low blood sugar.
D. Increased capillary refill time is generally a sign of poor perfusion or dehydration and is not specific to hypoglycemia. In hypoglycemia, the capillary refill time is usually normal, though other signs such as shakiness, sweating, or irritability are more indicative of low blood sugar levels.
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