The nurse is caring for a school-age girl who has had a cardiac catheterization. The child tells the nurse that her bandage is "too wet." The nurse finds the bandage and bed soaked with blood. What is the most appropriate initial nursing action?

The correct answer is Choice A.Choice A rationale:Vomiting is a common sign of digoxin toxicity. It occurs due to the drug's effects on the gastrointestinal system, which can lead to nausea and vomiting as the body attempts to expel the toxin. This symptom is particularly significant as it can indicate elevated digoxin levels that may require medical intervention.Choice B rationale:Tachycardia, or an increased heart rate, can occur with digoxin toxicity; however, it is more commonly associated with inadequate therapeutic levels rather than toxicity itself. Digoxin usually causes bradycardia (a slower heart rate) when at therapeutic levels, making tachycardia less indicative of toxicity.Choice C rationale:Bradypnea, or slow breathing, is not a typical sign of digoxin toxicity. While respiratory issues can arise from various conditions, they are not specifically linked to digoxin levels. Monitoring respiratory rate is essential in clinical settings but does not directly correlate with digoxin toxicity.Choice D rationale:Seizures are not a common sign of digoxin toxicity. While severe cases might lead to neurological symptoms due to electrolyte imbalances or other complications, seizures are not typically associated with digoxin overdose. Instead, they may suggest other underlying issues requiring evaluation.

The correct answer is choice C. Explain in simple terms how it works.

Choice A rationale:

Asking the girl why she wants to know might be appropriate in some contexts, but children are naturally curious and seeking information is a common behavior. Explaining how the blood pressure apparatus works would likely be more beneficial than questioning her motivation.

Choice B rationale:

Determining why she is anxious assumes that the girl is anxious, which might not be the case. Additionally, the question she asked does not necessarily indicate anxiety, but rather a curiosity about the medical equipment.

Choice C rationale:

Explaining in simple terms how the blood pressure apparatus works is the most appropriate nursing action. This approach respects the child's curiosity and provides her with age-appropriate information, fostering a positive and educational interaction.

Choice D rationale:

Telling her that she will see how it works as it is used might not fully satisfy her curiosity or address her immediate question. Children often benefit from clear and concise explanations, especially when it comes to medical equipment.