The nurse is preparing to administer medications for an eight-month-old infant with heart failure. The infant has a blood pressure of 114/66 mm Hg, apical pulse of 88 beats/minute, and respirations of 30 breaths/minute.

Which medication should the nurse withhold until the healthcare provider is notified?

Digoxin.

Furosemide.

Hydralazine.

Enalapril.

Answer and Explanation

The Correct Answer is A

For an eight-month-old infant with heart failure, the nurse should withhold digoxin if the infant's apical pulse is less than 90 beats/minute and notify the healthcare provider. In this case, the infant's apical pulse is 88 beats/minute, so the nurse should withhold the digoxin and notify the healthcare provider.

Furosemide ( B), hydralazine (C), and enalapril (D) do not have specific parameters for withholding based on the infant's vital signs.

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Correct Answer is C

Explanation

The nurse should recognize that the statement "high-calorie formula encourages increased growth" is an appropriate understanding of interventions for an infant with FTT. High-calorie formula can help infants who are not gaining weight adequately to increase their calorie intake and promote growth.

Breast milk provides adequate nutrition for most infants, but in cases of FTT, the infant may require a higher calorie intake than breast milk can provide. Regular syringe feedings and fruit juice are not recommended interventions for FTT. Syringe feedings can cause aspiration and fruit juice does not provide the appropriate balance of nutrients needed for an infant's growth and development.

A. Administer topical antibiotic therapy daily. B. Provide passive range of motion exercises. C. Ensure no weight bearing on the aﬀected extremity. D. Schedule ice pack applications to the infected area.

Correct Answer is C

Explanation

During the initial phase of treatment for osteomyelitis, the nurse should instruct the child and parent to ensure that there is no weight bearing on the aﬀected extremity. This may require the use of assistive devices such as crutches or a wheelchair. Administering topical antibiotic therapy, providing passive range of motion exercises, and scheduling ice pack applications to the infected area are not appropriate interventions during the initial phase of treatment.

Topical antibiotics may be used later in the course of treatment, after the initial phase of intravenous antibiotics has been completed.

Passive range of motion exercises may be appropriate during the later phases of treatment to prevent joint contractures.

Ice pack applications may be appropriate for pain relief, but they are not a primary intervention for osteomyelitis.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is providing nutrition education to the parents of an infant with failure to thrive (FTT). Which statement made by the parent should the nurse recognize as an appropriate understanding of interventions?

Correct Answer is C

Explanation

The nurse is providing teaching to a school-age child with left femoral osteomyelitis and the child's parent prior to discharge. Which instruction should the nurse provide related to the initial phase of treatment?

Correct Answer is C

Explanation

The nurse is teaching the parents about important dietary changes for their child who is newly diagnosed with celiac disease. Which foods should the nurse include in the list of allowed foods for this child?

The nurse is assessing a preschool-aged child who presents with ﬂank pain, dysuria, and low-grade fever. To determine a possible urinary tract infection, which additional information should the nurse gather from the parent?

The nurse is giving an intramuscular injection of an antibiotic to a 16-month-old toddler with pneumonia. The toddler does not have any known allergies and has been walking without assistance for one month. Which technique should the nurse select for administration?

The nurse is assessing a 6-month-old infant. Which response requires further evaluation by the nurse?

The nurse begins collecting the medical history of a child when the child screams and tries to hide behind the parent, dropping a stuﬀed toy. Which intervention should the nurse implement?

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