The nurse is getting ready to give medications to an eight-month-old infant diagnosed with heart failure.

The infant’s vital signs are as follows: blood pressure 114/66 mm Hg, apical pulse 88 beats/minute, and respirations 30 breaths/minute.

Which medication should the nurse hold and inform the health care provider?

Enalapril

Digoxin

Furosemide

Hydralazine

Answer and Explanation

The Correct Answer is B

Choice A rationale
Enalapril is an angiotensin-converting enzyme (ACE) inhibitor commonly used in the treatment of heart failure. It works by widening blood vessels, which reduces the workload of the heart and helps keep heart failure from getting worse. In the given scenario, there is no specific indication to hold Enalapril based on the infant’s vital signs.
Choice B rationale
Digoxin is a medication that can help the heart beat stronger with a more regular rhythm. However, it is important to monitor the patient’s heart rate when administering Digoxin, as it can lower the heart rate. In this case, the infant’s apical pulse is 88 beats/minute, which is lower than the normal range for an eight-month-old infant (normal range: 100-160 beats/minute). Therefore, the nurse should hold the Digoxin and inform the healthcare provider.
Choice C rationale
Furosemide is a diuretic that helps the kidneys get rid of extra fluid that may build up in the body. It is often used in the treatment of heart failure to relieve symptoms such as fluid retention. In the given scenario, there is no specific indication to hold Furosemide based on the infant’s vital signs.
Choice D rationale
Hydralazine is a medication used to treat high blood pressure. It works by relaxing and widening blood vessels so blood can flow more easily. In the given scenario, there is no specific indication to hold Hydralazine based on the infant’s vital signs.

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Correct Answer is B

Explanation

Choice A rationale
While infant formula is a common feeding option, it does not enhance the absorption of iron. In fact, iron is better absorbed when taken with vitamin C, which is abundant in orange juice.
Choice B rationale
The mother is correctly administering the iron drops. Giving iron with orange juice can enhance iron absorption due to the vitamin C content.
Choice C rationale
Mixing the iron drops in the orange juice is not necessary and could potentially alter the taste of the juice.
Choice D rationale
There is no need to refrain from feeding the infant for 30 minutes after giving the iron drops.

A. Compare the child’s vital signs over the past three weeks. B. Counsel the parents to pay more attention to the child. C. Ask the boy to describe a typical day at school. D. Conduct a complete neurological assessment.

Correct Answer is C

Explanation

The correct answer is: C

Choice A reason: Comparing the child’s vital signs over the past three weeks could provide data on any changes in his physical health status. However, without additional context, this information alone may not be sufficient to determine the cause of his symptoms. Vital signs are typically within the following ranges for a healthy 10-year-old: temperature 97.8°F to 99.1°F (36.5°C to 37.3°C), pulse 70 to 110 beats per minute, respirations 17 to 22 breaths per minute, and blood pressure 90/60 mmHg to 120/80 mmHg.

Choice B reason: Counseling the parents to pay more attention to the child might be helpful if the child’s symptoms are due to emotional neglect or lack of parental involvement. However, this intervention assumes that the parents are not attentive without evidence and does not directly address the child’s reported symptoms.

Choice C reason: Asking the boy to describe a typical day at school is a non-invasive way to gather more information about potential stressors or issues that could be contributing to his symptoms. This approach can help identify if the symptoms are related to school environment, bullying, academic pressure, or other psychosocial factors.

Choice D reason: Conducting a complete neurological assessment would be appropriate if there were specific indications of neurological issues. Since the boy’s symptoms are non-specific and could be related to a variety of causes, including stress or anxiety, a neurological assessment might not be the most immediate step without further evidence suggesting a neurological cause.

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Naxlex Comprehensive Predictor Exams

The nurse observes a mother administering ferrous sulfate (iron drops) to her 11-month-old child, followed by 2 ounces (60 mL) of orange juice. What should be the nurse’s subsequent action?

Correct Answer is B

Explanation

A 10-year-old boy has been seen frequently by the school nurse over the past three weeks after school begins in the fall. He reports headaches, stomach aches, and difficulty sleeping. Which intervention should the nurse implement?

Correct Answer is C

Explanation

A child has been prescribed loratadine 5 mg to be taken orally once a day. The bottle is labeled “Loratadine for Oral Suspension, USP 5 mg per 5 mL.”. How many teaspoons should the nurse instruct the parent to give with each dose?

A 9-week-old infant is scheduled for a cleft lip repair. What information is most important for the nurse to convey to the surgeon before transporting the infant to the surgical suite?

The nurse is caring for a school-age child with crusting and swollen eyelids, purulent drainage, and inflamed conjunctiva. The child receives a prescription for an ophthalmic antinfective ointment. What instruction should the nurse provide the child’s caregivers during discharge education?

When initiating a peripheral intravenous (IV) infusion on an infant, what action should the nurse take?

A nurse is educating parents about essential dietary modifications for their child, who has recently been diagnosed with celiac disease. Which foods should the nurse include in the list of permissible foods for this child?

The nurse is caring for an adolescent with type 1 diabetes mellitus who presents with an HbA1c of 11% (97 mmol/mol), thirst, and blurred vision. What action should the nurse take first?

The nurse is educating the caregiver of a school-age child who has recently been diagnosed with attention-deficit hyperactivity disorder (ADHD). Which of the caregiver’s statements indicate that they have understood the education? (Select all that apply.)

The nurse is planning care for a 16-year-old, who has juvenile idiopathic arthritis (JIA). The nurse includes activities to strengthen and mobilize the joints and surrounding muscle. Which physical therapy regimen should the nurse encourage the adolescent to implement?