Nokea
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/minute
- 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: Withholding digoxin if the infant's heart rate is below 100 beats/minute prevents potential toxicity and ensures safety.
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What should be the main focus of the nurse when presenting information?
- A. Pharmacological treatment
- B. Surgical interventions available
- C. Patient education
- D. Reduction of aerobic exercise
Correct Answer: C
Rationale: Patient education is the primary focus of a hypertension-prevention program to promote lifestyle changes and awareness.
What does the nurse recognize as a sign of digoxin toxicity?
- A. Restlessness
- B. Decreased respiratory rate
- C. Increased urinary output
- D. Vomiting
Correct Answer: D
Rationale: Vomiting is a common sign of digoxin toxicity, along with nausea, anorexia, and pulse irregularities.
What is accurate about the characteristics of high-density lipoproteins (HDLs)?
- A. They have high amounts of triglycerides.
- B. They have only small amounts of protein.
- C. They have little cholesterol.
- D. They aid in steroid production.
Correct Answer: C
Rationale: HDLs have low triglycerides, high protein content, low cholesterol, and are excreted via the liver, not involved in steroid production.
What are the four structural heart anomalies that make up the tetralogy of Fallot?
- A. Hypertrophied right ventricle
- B. Patent ductus arteriosus
- C. Ventral septal defect
- D. Narrowing of pulmonary artery
- E. Dextroposition of aorta
Correct Answer: A,B,D,E
Rationale: Tetralogy of Fallot includes a hypertrophied right ventricle, patent ductus arteriosus, pulmonary artery stenosis, and dextroposition of the aorta. Note: The document incorrectly lists 'ventral septal defect' instead of 'ventricular septal defect,' but the correct term is assumed.
Which statement by the father leads the nurse to determine he understood the instructions?
- A. If the baby turns blue, I will hold him against my shoulder with his knees bent up toward his chest.'
- B. If the baby turns blue, I will lay him down on a firm surface with his head lower than the rest of his body.'
- C. If the baby turns blue, I will immediately put the baby upright in an infant seat.'
- D. If the baby turns blue, I will put the baby in supine position with his head elevated.'
Correct Answer: A
Rationale: The knee-chest position during a hypercyanotic spell in tetralogy of Fallot increases venous return and reduces cyanosis.