The nurse is caring for a pediatric patient receiving digoxin therapy. Which assessment finding would indicate digoxin toxicity?

Pedal edema.

Cardiac arrhythmias.

Circumoral cyanosis.

Infrequent voiding.

Answer and Explanation

The Correct Answer is B

Choice A rationale:

Pedal edema is not indicative of digoxin toxicity. Digoxin toxicity primarily affects the heart's electrical activity and rhythm, not fluid accumulation in the extremities.

Choice B rationale:

Cardiac arrhythmias are a hallmark sign of digoxin toxicity. Digoxin can lead to various types of arrhythmias, such as atrial tachycardia, atrial fibrillation, and ventricular ectopy. This occurs due to the drug's effects on altering the electrical conduction in the heart.

Choice C rationale:

Circumoral cyanosis is not a typical sign of digoxin toxicity. This symptom might be seen in conditions like methemoglobinemia or respiratory distress, but it's not directly related to digoxin toxicity.

Choice D rationale:

Infrequent voiding is not a specific sign of digoxin toxicity. It could be related to various factors, such as fluid intake, renal function, or underlying medical conditions, but it's not a hallmark of digoxin toxicity.

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Correct Answer is B

Explanation

Choice A rationale:

The identification band falling off the patient's leg is a documentation concern and doesn't require immediate action unless the patient is at risk of wandering or abduction.

Choice B rationale:

IV fluids should be changed every 24 hours to prevent bacterial growth and infection. Using fluids that are 48 hours old increases the risk of introducing infection to the patient.

Choice C rationale:

The crib rails being halfway up is not an immediate concern unless the child is at risk of falling or climbing out of the crib.

Choice D rationale:

Damp bed linen can be addressed during the next bedding change. It may not require immediate action unless the patient's skin integrity is at risk.

A. "We will return to the hospital if my child spits up blood.". B. "I'll give my child cherry gelatin since that is her favorite.". C. "We will return to the hospital if my child develops difficulty breathing.". D. "I'll have my child rinse her mouth frequently with water to prevent a bad breath odor.".

Correct Answer is B

Explanation

Choice A rationale:

Returning to the hospital if the child spits up blood is a correct response as it indicates the recognition of potential postoperative bleeding.

Choice B rationale:

Giving the child cherry gelatin, even though it's the child's favorite, might not be appropriate after a tonsillectomy/adenoidectomy, as certain foods can irritate the healing throat.

Choice C rationale:

Returning to the hospital if the child develops difficulty breathing is a necessary step to address any respiratory distress.

Choice D rationale:

Having the child rinse her mouth frequently with water to prevent a bad breath odor is a suitable suggestion to maintain oral hygiene and comfort after surgery. In all three scenarios, the rationale for the correct answers revolves around patient safety, comfort, and appropriate post-operative care. The incorrect choices in each question either introduce potential complications, misunderstandings, or actions that might compromise the patient's well-being.

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The nurse is caring for a pediatric patient receiving digoxin therapy. Which assessment finding would indicate digoxin toxicity?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a 2-year-old patient. Which observation requires immediate action by the nurse?

Correct Answer is B

Explanation

The nurse is providing discharge instructions to the parent of a patient who had a tonsillectomy/adenoidectomy. Which statement would indicate that the parent needs further teaching?

Correct Answer is B

Explanation

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