A nurse is preparing to administer digoxin to a pediatric client who has heart failure. Which of the following actions is appropriate?
Instructing the client to eat foods that are low in potassium.
Repeat the dose if the client spits it out.
Measuring apical pulse rate for 30 seconds before administration.
Evaluating the client for nausea, vomiting, and anorexia.
The Correct Answer is C
A. Clients on digoxin should actually have an adequate intake of potassium, as low potassium levels can increase the risk of digoxin toxicity.
B. If a pediatric client spits out digoxin, the dose should not be repeated automatically; instead, the nurse should assess the situation and follow the facility's protocol regarding missed doses.
C. Measuring the apical pulse for one full minute before administering digoxin is critical; if the pulse is below the established threshold (usually <60 bpm for children), the medication should be held and the provider notified.
D. While evaluating for nausea, vomiting, and anorexia is important, it is not an appropriate immediate action before administering the medication. The priority action is to assess the apical pulse.
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Correct Answer is ["C","D","E"]
Explanation
A. Pertussis primarily affects the respiratory tract rather than just the nostrils.
B. Pertussis is caused by the bacterium Bordetella pertussis, making it a bacterial infection, not viral.
C. The bacteria release toxins that damage the cilia of the epithelial cells in the respiratory tract, disrupting their function.
D. Inflammation occurs in the lungs and airway due to the infection, contributing to symptoms such as cough.
E. The infection leads to excessive secretions that are difficult to expel, resulting in the characteristic whooping cough associated with pertussis.
Correct Answer is C
Explanation
A. By age 6, while children can dress themselves, they may still need assistance with more complex grooming tasks, making this statement too absolute.
B. Counting backwards from 20 to 1 is typically expected by age 8, not age 7, indicating this statement is inaccurate regarding cognitive development.
C. Engaging in motor activities that require balance, such as jumping rope, is appropriate for children around age 6, demonstrating the expected physical development in this age group.
D. While children can use simple tools, mastery and effective use of tools like a screwdriver or hammer are more typical around ages 8 to 10, making this statement premature for age 6.