Discharge teaching for a 3-month-old infant with a cardiac defect who is to receive digoxin (Lanoxin) should include which of the following?
- A. Give the medication at regular intervals.
- B. Mix the medication with a small volume of breast milk or formula.
- C. Repeat the dose one time if the child vomits immediately after administration.
- D. Notify the primary care provider of poor feeding or vomiting.
- E. Make up any missed doses as soon as realized.
- F. Notify the primary care provider if more than 2 consecutive doses are missed.
- G. Keep medication in a safe place, preferably a locked cabinet.
Correct Answer: A,C,D,F,G
Rationale: Digoxin requires regular dosing, safe storage, and monitoring for side effects like vomiting or poor feeding. Vomiting doses should not be repeated due to toxicity risks, and missed doses should not be made up.
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A school-age client admitted to the hospital because of decreased urine output and periorbital edema is diagnosed with acute poststreptococcal glomerulonephritis. Which of the following actions should receive the highest priority?
- A. Assessing vital signs every 4 hours.
- B. Monitoring intake and output every 12 hours.
- C. Obtaining daily weight measurements.
- D. Obtaining serum electrolyte levels daily.
Correct Answer: C
Rationale: Weight reflects fluid status.
An infant is to be discharged after surgery for intussusception. In developing the discharge teaching plan, the nurse should tell the mother?
- A. The infant will experience a change in the normal home routine.
- B. The infant can return to the prehospital routine immediately.
- C. The infant needs to ingest more calories at home than normal.
- D. The infant will continue to experience abdominal cramping for a few days.
Correct Answer: B
Rationale: After successful surgery, the infant can typically resume normal routines unless complications arise.
A child who limps and has pain has been found to have Legg-Calvé-Perthes disease. What should the nurse expect to include in the child's plan of care?
- A. Initiation of pain control measures, especially at night when acute.
- B. Promotion of ambulation despite child's discomfort in the affected hip.
- C. Prevention of flexion in the affected hip and knee.
- D. Advance of weight bearing on the head of the affected femur.
Correct Answer: A
Rationale: Pain control is essential in Legg-Calvé-Perthes disease, as pain is a common symptom, especially at night, due to inflammation and muscle spasms.
A nurse is reviewing a hospital's protocol for managing pediatric ingestions. Which step should be prioritized in the protocol?
- A. Administer an antidote immediately.
- B. Obtain a detailed history of the ingestion.
- C. Perform a physical examination.
- D. Order laboratory tests.
Correct Answer: B
Rationale: A detailed history (substance, amount, time) guides management decisions. Antidotes, exams, or labs follow based on history findings.
The nurse is preparing to administer the last dose of ceftriaxone (Rocephin) before discharge to a 1-year-old but finds the I.V. has occluded. The nurse should:
- A. Restart the I.V.
- B. Administer the medication intramuscularly.
- C. Arrange for early discharge.
- D. Ask the provider to request an order change.
Correct Answer: B
Rationale: Administering ceftriaxone intramuscularly is appropriate when the I.V. is occluded, ensuring the child receives the final dose before discharge.
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