Nokea
A nurse is caring for a group of toddlers receiving digoxin therapy. For which of the following clients should the nurse plan to hold the dose of digoxin?
- A. A toddler who has an apical pulse of 100 bpm
- B. A toddler who has a potassium level of 4.0 mEq/L (3.6 to 5.2 mEq/L)
- C. A toddler who has a digoxin level of 1.2 ng/mL (0.8 to 2.0 ng/mL)
- D. A toddler who has vomited 2 times in the last hour
Correct Answer: D
Rationale: The correct answer is D because vomiting can lead to decreased absorption of digoxin, potentially resulting in subtherapeutic levels. Holding the dose in this situation prevents giving an ineffective dose. Option A is incorrect because an apical pulse of 100 bpm is within the normal range for toddlers on digoxin. Option B is incorrect because a potassium level of 4.0 mEq/L is also within the normal range. Option C is incorrect because a digoxin level of 1.2 ng/mL falls within the therapeutic range.
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A nurse is assessing a 5-year-old child who has diabetes insipidus and is receiving desmopressin. Which of the following findings should the nurse identify as an indication that the medication is effective?
- A. Heart rate 140/min
- B. Capillary refill 3 seconds
- C. Absence of hypoglycemic episodes
- D. Cessation of nocturnal enuresis
Correct Answer: D
Rationale: The correct answer is D: Cessation of nocturnal enuresis. Desmopressin is a medication used to treat diabetes insipidus by decreasing urine output. Nocturnal enuresis is a common symptom of diabetes insipidus due to excessive urine production at night. Therefore, the cessation of nocturnal enuresis indicates that the medication is effectively reducing urine output in the child. Choices A, B, and C are unrelated to the effectiveness of desmopressin in treating diabetes insipidus. Choice A, heart rate of 140/min, is not a specific indicator of desmopressin effectiveness. Choice B, capillary refill of 3 seconds, is a measure of peripheral perfusion and not directly related to diabetes insipidus. Choice C, absence of hypoglycemic episodes, is more relevant to diabetes mellitus and not diabetes insipidus.
A nurse is providing teaching about home safety to the adult child of an older adult client who is postoperative following knee replacement surgery. Which of the following instructions should the nurse include?
- A. Encourage the client to avoid wearing shoes at home.
- B. Place a throw rug over electrical cords.
- C. Mark the edges of the doorway to the house with tape.
- D. Ensure that area rugs have rubber backs.
Correct Answer: D
Rationale: The correct answer is D: Ensure that area rugs have rubber backs. This instruction is important to prevent slips and falls, as rubber-backed rugs provide better traction on smooth surfaces, reducing the risk of accidents. Placing throw rugs over electrical cords (B) can cause tripping hazards. Marking the edges of the doorway with tape (C) may not be effective and can be unsightly. Encouraging the client to avoid wearing shoes at home (A) may not directly impact safety. Overall, ensuring area rugs have rubber backs (D) is the most practical and effective approach to enhancing home safety for a postoperative older adult.
A nurse in the emergency department is caring for a 10-year-old child. The nurse is assessing the child. Which of the following findings require follow-up? Select the 5 findings that require follow-up.
- A. Temperature
- B. Heart rate
- C. Report of pain
- D. Respiratory rate
- E. Tonsillar findings
- F. Oxygen saturation
Correct Answer: A,B,C,D,E,F
Rationale: The correct answer includes all options (A, B, C, D, E, F) because they are essential vital signs and key indicators of the child's health status. Temperature (A), heart rate (B), respiratory rate (D), and oxygen saturation (F) are crucial physiological parameters that can indicate underlying health issues if abnormal. Report of pain (C) is important to assess the child's comfort and potential underlying conditions. Tonsillar findings (E) could indicate infections or other throat issues. Follow-up on all these findings is necessary for a comprehensive assessment of the child's health.
A nurse in an emergency department is caring for a 3-year-old child who has suspected epiglottitis. Which of the following actions should the nurse take?
- A. Prepare to assist with intubation.
- B. Obtain a throat culture.
- C. Suction the child's oropharynx.
- D. Prepare a cool mist tent.
Correct Answer: A
Rationale: The correct answer is A: Prepare to assist with intubation. Epiglottitis is a medical emergency that can cause rapid airway obstruction. Intubation ensures a secure airway and oxygenation. Throat culture (B) is not a priority in this acute situation. Suctioning (C) can provoke spasm and worsen obstruction. Cool mist tent (D) does not address the immediate need for securing the airway.
A nurse is caring for a child who has cystic fibrosis and requires postural drainage. Which of the following actions should the nurse take?
- A. Perform the procedure prior to meals.
- B. Hold hand flat to perform percussions on the child.
- C. Administer a bronchodilator after the procedure.
- D. Perform the procedure twice each day.
Correct Answer: A
Rationale: The correct answer is A. Performing postural drainage prior to meals helps prevent aspiration of food or stomach contents during the procedure. Postural drainage is typically done 1-2 hours after meals to minimize the risk of aspiration. Holding the hand flat (B) is incorrect as cupped hands are used for percussion to avoid injury. Administering a bronchodilator after (C) can lead to increased mucous production. Performing the procedure twice daily (D) is generally recommended, but the timing in relation to meals is crucial.