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Which is the most appropriate nursing action related to the administration of digoxin (Lanoxin) to an infant?
- A. Counting the apical rate for 30 seconds before administering the medication
- B. Withholding a dose if the apical heart rate is less than 100 beats/min
- C. Repeating a dose if the child vomits within 30 minutes of the previous dose
- D. Checking respiratory rate and blood pressure before each dose
Correct Answer: B
Rationale: As a rule, if the pulse rate of an infant is below 100 beats/min, the medication is withheld and the physician is notified.
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The nurse is caring for a child with cystic fibrosis. Which intervention is most important when the child is hospitalized with a respiratory infection?
- A. Administer prescribed antibiotics as soon as possible.
- B. Increase fluid intake to help thin mucus.
- C. Provide respiratory treatments and postural drainage.
- D. Encourage high-calorie, high-protein meals.
Correct Answer: C
Rationale: Respiratory treatments and postural drainage are critical to help clear mucus from the lungs in children with cystic fibrosis, especially during respiratory infections.
A child has an elevated antistreptolysin O (ASO) titer. Which combination of symptoms, in conjunction with this finding, would confirm a diagnosis of rheumatic fever?
- A. Subcutaneous nodules and fever
- B. Painful, tender joints, and carditis
- C. Erythema marginatum and arthralgia
- D. Chorea and elevated sedimentation rate
Correct Answer: B
Rationale: The presence of two major Jones criteria would indicate a high probability of rheumatic fever.
In Asia, the following hepatitis virus appears to be a significant cause of viral myocarditis
- A. hepatitis E virus
- B. hepatitis B virus
- C. hepatitis C virus
- D. hepatitis D virus
Correct Answer: A
Rationale: Hepatitis E virus has been identified as a significant cause of viral myocarditis in Asia.
A client with ulcerative colitis is admitted to the medical unit during an acute exacerbation. The nurse should instruct the unlicensed assistive personnel (UAP) to report which finding related to the client's bowel movements?
- A. Hard pellets of stool
- B. Clay-colored stool
- C. Stool with fatty streaks
- D. Blood in the stool
Correct Answer: D
Rationale: Blood in the stool is a common finding during an acute exacerbation of ulcerative colitis, which is an inflammatory condition of the colon.
Features differentiating renal tubular acidosis type II from type I include:
- A. Increased anion gap
- B. Nephrocalcinosis
- C. Urinary pH can be lowered < 5.5 in ammonium chloride loading test in type I
- D. Aminoaciduria
Correct Answer: C
Rationale: In type I renal tubular acidosis, urinary pH can be lowered below 5.5 during an ammonium chloride loading test, unlike in type II.