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)

Answer and Explanation

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.

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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.

A. Use a hair dryer on cool setting to relieve itching. B. Examine the child for skin irritation at the cast edges. C. Restrict the child's strenuous activities for 3 days. D. Monitor for pallor or swelling in the child's affected hand.

Correct Answer is D

Explanation

A. Using a hair dryer on a cool setting can help relieve itching, but it is not as critical as ensuring circulation in the affected limb.

B. Skin irritation at the cast edges should be monitored but is not the most immediate concern.

C. Restricting strenuous activities is important, but it is secondary to monitoring for signs of complications like poor circulation or swelling.

D. Monitoring for pallor or swelling is the priority, as it can indicate complications such as impaired circulation, compartment syndrome, or increased pressure within the cast.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

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Correct Answer is D

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