A nurse is preparing to administer digoxin to a pediatric client who has heart failure. Which of the following actions is appropriate?
Instructing the client to eat foods that are low in potassium.
Repeat the dose if the client spits it out.
Measuring apical pulse rate for 30 seconds before administration.
Evaluating the client for nausea, vomiting, and anorexia.
The Correct Answer is C
A. Clients on digoxin should actually have an adequate intake of potassium, as low potassium levels can increase the risk of digoxin toxicity.
B. If a pediatric client spits out digoxin, the dose should not be repeated automatically; instead, the nurse should assess the situation and follow the facility's protocol regarding missed doses.
C. Measuring the apical pulse for one full minute before administering digoxin is critical; if the pulse is below the established threshold (usually <60 bpm for children), the medication should be held and the provider notified.
D. While evaluating for nausea, vomiting, and anorexia is important, it is not an appropriate immediate action before administering the medication. The priority action is to assess the apical pulse.
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Related Questions
Correct Answer is ["A","E","F"]
Explanation
A. Providing privacy during personal care and procedures is essential for adolescents, as it helps them feel more secure and respected during a vulnerable time.
B. This option is incorrect; discussing changes related to puberty can help the adolescent understand their body and promote healthy coping mechanisms.
C. Treating the adolescent as if they are not competent undermines their autonomy and can negatively impact their self-esteem; adolescents should be involved in their care and decision-making when appropriate.
D. Disregarding confidentiality can lead to a breakdown of trust; it is important to respect the adolescent's privacy while also keeping parents informed within appropriate limits.
E. Showing respect for the client's feelings and concerns helps validate their experiences and fosters a supportive environment during a challenging time.
F. Listening carefully to the client’s thoughts and concerns encourages open communication, allowing the nurse to address any worries and support the adolescent’s emotional needs.
Correct Answer is B
Explanation
A. This statement is incorrect; the spacer does not primarily increase medication delivery to the oropharynx.
B. The spacer helps to increase the amount of medication that reaches the lungs by allowing larger particles to settle out and preventing them from being deposited in the mouth and throat.
C. Inhaling slowly and deeply is recommended for effective medication delivery when using an MDI with a spacer.
D. Covering the exhalation slots would prevent proper airflow and could cause the child to inhale exhaled air, which is not recommended during inhalation.
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