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.
Free Nursing Test Bank
- Free Pharmacology Quiz 1
- Free Medical-Surgical Quiz 2
- Free Fundamentals Quiz 3
- Free Maternal-Newborn Quiz 4
- Free Anatomy and Physiology Quiz 5
- Free Obstetrics and Pediatrics Quiz 6
- Free Fluid and Electrolytes Quiz 7
- Free Community Health Quiz 8
- Free Promoting Health across the Lifespan Quiz 9
- Free Multidimensional Care Quiz 10
View Related questions
Correct Answer is D
Explanation
A. Administering antibiotics is not appropriate as Kawasaki disease is not caused by a bacterial infection; it is an inflammatory condition.
B. While monitoring for signs of coronary artery aneurysms is essential, the immediate intervention needed in the initial phase is to administer IVIG to mitigate inflammation and prevent complications.
C. Providing comfort measures for peeling skin is supportive but does not address the critical treatment needs in Kawasaki disease.
D. Administering intravenous immunoglobulin (IVIG) is the priority nursing intervention as it helps reduce inflammation and the risk of developing cardiovascular complications associated with Kawasaki disease.
Correct Answer is ["C","D"]
Explanation
A. The child should avoid tub baths or submerging in water for several days post-procedure to reduce the risk of infection and keep the catheter site dry; sponge baths are usually recommended.
B. Keeping the child home for an entire week may be excessive; the duration of home care typically depends on the child's recovery, and many children can return to school sooner if they feel well.
C. Offering clear liquids for the first 24 hours helps ensure the child stays hydrated and allows for easier digestion following anesthesia or sedation.
D. Giving acetaminophen for discomfort is appropriate, as it can help manage any pain or discomfort the child may experience after the procedure, and is usually a recommended practice.