The nurse is getting ready to give medications to an eight-month-old infant diagnosed with heart failure.
The infant’s vital signs are as follows: blood pressure 114/66 mm Hg, apical pulse 88 beats/minute, and respirations 30 breaths/minute.
Which medication should the nurse hold and inform the health care provider?
Enalapril
Digoxin
Furosemide
Hydralazine
The Correct Answer is B
Choice A rationale
Enalapril is an angiotensin-converting enzyme (ACE) inhibitor commonly used in the treatment of heart failure. It works by widening blood vessels, which reduces the workload of the heart and helps keep heart failure from getting worse. In the given scenario, there is no specific indication to hold Enalapril based on the infant’s vital signs.
Choice B rationale
Digoxin is a medication that can help the heart beat stronger with a more regular rhythm. However, it is important to monitor the patient’s heart rate when administering Digoxin, as it can lower the heart rate. In this case, the infant’s apical pulse is 88 beats/minute, which is lower than the normal range for an eight-month-old infant (normal range: 100-160 beats/minute). Therefore, the nurse should hold the Digoxin and inform the healthcare provider.
Choice C rationale
Furosemide is a diuretic that helps the kidneys get rid of extra fluid that may build up in the body. It is often used in the treatment of heart failure to relieve symptoms such as fluid retention. In the given scenario, there is no specific indication to hold Furosemide based on the infant’s vital signs.
Choice D rationale
Hydralazine is a medication used to treat high blood pressure. It works by relaxing and widening blood vessels so blood can flow more easily. In the given scenario, there is no specific indication to hold Hydralazine based on the infant’s vital signs.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
The adolescent client’s symptoms of localized pain, swelling, and tenderness, particularly at night, are suggestive of a malignancy such as osteosarcoma, which is the most common primary bone tumor in children and adolescents. Radial ossification in the soft tissues is a characteristic finding in osteosarcoma and is indicative of bone production by malignant cells.
Choice B rationale
Hemosiderosis is a rare condition characterized by the accumulation of iron in various tissues, including the liver, spleen, and bone marrow. It may present with symptoms such as fatigue, joint pain, and abdominal pain, but is not typically associated with the symptoms and imaging findings described in the case scenario.
Choice C rationale
Growing pains are a common, benign condition that occur in children and do not typically present with the symptoms described in the case scenario.
Choice D rationale
Rhabdomyolysis is a medical emergency that involves the breakdown of skeletal muscle tissue and release of muscle fiber contents into the bloodstream. It can present with muscle pain, swelling, and tenderness, but typically occurs as a result of injury, infection, or drug toxicity.
Correct Answer is A
Explanation
Choice A rationale
In evaluating a preschool-aged child presenting with symptoms of flank pain, dysuria, and a low-grade fever for a possible urinary tract infection (UTI), the nurse should obtain additional information from the parent about the frequency of urination. Increased frequency of urination is a common symptom of UTI in children.
Choice B rationale
While dietary changes can affect the color and odor of urine, they are not typically associated with the symptoms of a UTI.
Choice C rationale
Unusual odors in the urine can be a sign of a UTI. However, this symptom alone is not definitive for a UTI and should be considered in conjunction with other symptoms and findings.
Choice D rationale
Changes in the color of the urine can be a sign of a UTI, as the urine may appear cloudy or have a pink or red color due to the presence of blood. However, this symptom alone is not definitive for a UTI and should be considered in conjunction with other symptoms and findings.
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