A nurse is caring for an infant who has heart failure and vomited following administration of digoxin. Which of the following actions should the nurse take?
Administer the next dose as prescribed
Mix the medication with 8 oz of formula
Give an antiemetic.
Increase fluid intake.
The Correct Answer is A
A. Vomiting after administering digoxin could be a sign of digoxin toxicity or intolerance. Before giving another dose, it is crucial to assess the infant’s condition, check for signs of digoxin toxicity, and consult with the healthcare provider. Administering the next dose without addressing the underlying issue could worsen the situation.
B. Mixing digoxin with a large volume of formula is not recommended. Digoxin should be administered in precise doses, and diluting it in such a large volume could lead to inaccuracies in dosing. Furthermore, mixing medication with formula does not address the issue of vomiting or potential toxicity.
C. While giving an antiemetic might seem like a solution to vomiting, it does not address the root cause of the vomiting, which could be related to digoxin toxicity or another issue. The first step should be to
assess the situation and determine if the vomiting is related to digoxin levels, and then consult with the healthcare provider. They may recommend appropriate interventions based on the infant’s condition.
D. Increasing fluid intake might be beneficial to prevent dehydration from vomiting, but it does not address the potential underlying cause of the vomiting, which could be related to digoxin toxicity. It is important to focus on the underlying cause and consult with the healthcare provider to determine the appropriate action. Managing fluid intake alone does not resolve the issue with digoxin or its side effects.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Phototherapy can increase a newborn's body temperature. Frequent monitoring is essential to prevent overheating.
B. Mittens may be used but their use is not directly related to phototherapy.
C. Applying lotion can interfere with the effectiveness of phototherapy. The newborn's skin should be kept clean and dry.
D. The newborn's eyes should be checked more frequently, typically every 4 hours, to monitor for any irritation or inflammation caused by the light.
Correct Answer is A
Explanation
A. Facial twitching could be a sign of neurological complications, such as a stroke, which is a serious complication of sickle cell disease. This finding requires immediate medical attention.
B. Kyphosis is a common postural abnormality that can occur in children with sickle cell disease due to chronic pain and limited activity but is not a priority finding.
C. Enuresis, or bedwetting, is not uncommon in children with chronic illnesses but is not a priority finding in this context.
D. Constipation is a common problem in children with sickle cell disease due to dehydration and decreased activity but is not a priority finding.
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