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 ["A","E","F"]
Explanation
A. Providing privacy during personal care and procedures is essential for adolescents, as it helps them feel more secure and respected during a vulnerable time.
B. This option is incorrect; discussing changes related to puberty can help the adolescent understand their body and promote healthy coping mechanisms.
C. Treating the adolescent as if they are not competent undermines their autonomy and can negatively impact their self-esteem; adolescents should be involved in their care and decision-making when appropriate.
D. Disregarding confidentiality can lead to a breakdown of trust; it is important to respect the adolescent's privacy while also keeping parents informed within appropriate limits.
E. Showing respect for the client's feelings and concerns helps validate their experiences and fosters a supportive environment during a challenging time.
F. Listening carefully to the client’s thoughts and concerns encourages open communication, allowing the nurse to address any worries and support the adolescent’s emotional needs.
Correct Answer is D
Explanation
A. Encouraging excessive rest and avoidance of physical activities can lead to feelings of inferiority by limiting opportunities for achievement and social interactions.
B. Limiting social interactions is counterproductive, as friendships and peer relationships are critical for social development during this stage.
C. While supervision is important, overly controlling the child’s activities can inhibit their ability to explore and learn, negatively impacting their sense of industry.
D. Involving the child in decision-making and providing opportunities for independent tasks fosters a sense of competence and accomplishment, essential for developing a sense of industry, according to Erikson’s theory.