A nurse is caring for an infant who has heart failure and a new prescription for digoxin.Which of the following findings should the nurse report to the provider?
Weight loss 0.25 kg (0.55 lb)
Vomiting twice in 4 hr
Respiratory rate 30/min
Heart rate 130/min
The Correct Answer is B
Choice A reason:
A weight loss of 0.25 kg (0.55 lb) may be within the range of normal fluctuation for an infant and may not necessarily warrant immediate reporting. However, it should be monitored closely.
Choice B reason:
Vomiting twice in 4 hours after receiving digoxin is a concerning finding. Digoxin has a narrow therapeutic range, and vomiting can lead to potential overdose. This should be reported to the provider for further evaluation.
Choice C reason:
A respiratory rate of 30/min may indicate increased work of breathing, which is a concern in an infant with heart failure. However, it is not specific to digoxin administration and may require
intervention but not immediate reporting.
Choice D reason:
A heart rate of 130/min is within the range of normal for an infant, especially one with heart failure. This finding is not specific to digoxin administration and may not warrant immediate reporting.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason:
Avoiding discussing the child's diagnosis with the sibling may create unnecessary secrecy and could hinder the sibling's understanding and coping.
Choice B reason:
Designating one parent to stay at home with the sibling may not be necessary, as both parents can still provide support and care for both children.
Choice C reason:
Avoiding having the sibling visit the child in the facility may isolate them and prevent opportunities for bonding and support.
Choice D reason:
This statement is correct. Encouraging phone calls between the siblings allows them to maintain communication, express their feelings, and support each other during the separation caused by hospitalization.
Correct Answer is C
Explanation
Choice A reason:
Increased alertness may be a sign of improved glucose levels, but it is not as direct an indicator as a blood glucose measurement.
Choice B reason:
Diaphoresis is a symptom of low blood glucose levels and indicates the need for intervention rather than effectiveness of therapy.
Choice C reason:
A blood glucose level of 50 mg/dL is within the normal range and indicates that the glucagon therapy has been effective in raising blood glucose levels.
Choice D reason:
The presence of urine ketones indicates that the body is using fats for energy, which may occur in the absence of adequate glucose. This is not an indicator of the effectiveness of glucagon therapy.
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