A nurse is caring for a group of toddlers receiving digoxin therapy. For which of the following toddlers should the nurse revise the plan of care?
A toddler who has an apical pulse of 100/min
A toddler who has a potassium level of 4.0 mEq/L (3.4 to 4.7 mEq/L)
A toddler who has vomited 2 times in the last hour
A toddler who has a digoxin level of 1.2 ng/mL (0.8 to 2 ng/mL)
The Correct Answer is C
A. An apical pulse of 100/min is within the normal range for a toddler. Digoxin should be administered cautiously if the heart rate is too low (below 90-100/min for young children), but 100/min is not a concern.
B. A potassium level of 4.0 mEq/L is within the normal range for toddlers (3.4-4.7 mEq/L), so there is no indication to revise the plan of care.
C. Vomiting is a sign of digoxin toxicity, and it requires immediate attention. The nurse should reassess the digoxin dose and check for other signs of toxicity, such as nausea, bradycardia, and arrhythmias.
D. A digoxin level of 1.2 ng/mL is within the therapeutic range for a toddler (0.8-2 ng/mL), so there is no need to revise the plan of care based on this finding.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Disposable diapers are not typically associated with healthcare-associated infections.
B. Protective plastic gowns are used to prevent transmission but do not contribute to healthcare-associated infections when used properly.
C. Unopened bottles of formula are safe from contamination until they are opened and prepared.
D. The bedside computer keyboard is a common source of healthcare-associated infection due to frequent handling and minimal cleaning, making it a vector for bacteria and viruses.
Correct Answer is B
Explanation
A. The anesthesiologist would typically explain their role, but the primary responsibility for explaining the procedure lies with the provider performing it.
B. If a guardian does not understand the procedure, the nurse should notify the provider to ensure that the guardian receives a full explanation. The provider is responsible for clarifying any misunderstandings regarding the procedure.
C. While the nurse can provide general information, the provider must explain the details of the procedure to ensure informed consent is obtained.
D. The nurse should not witness the consent unless the guardian fully understands and consents to the procedure.
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