ATI LPN
Wong's Essentials of Pediatric Nursing 11th Edition Test Bank
Chapter 23 : The Child with Cardiovascular Dysfunction Questions
Question 1 of 5
The nurse finds that a 6-month-old infant has an apical pulse of 166 beats/min during sleep. What nursing intervention is most appropriate at this time?
Correct Answer: C
Rationale: A sleeping pulse over 160 beats/min suggests tachycardia, an early sign of heart failure due to sympathetic stimulation, requiring practitioner evaluation. Oxygen or positioning may be needed later, but reporting is the priority. Recording alone delays intervention.
Question 2 of 5
What drug is an angiotensin-converting enzyme (ACE) inhibitor?
Correct Answer: B
Rationale: Captopril is an ACE inhibitor used in heart failure management. Furosemide is a loop diuretic, chlorothiazide acts on distal tubules, and spironolactone is a potassium-sparing diuretic, none of which are ACE inhibitors.
Question 3 of 5
A 2-year-old child is receiving digoxin (Lanoxin). The nurse should notify the practitioner and withhold the medication if the apical pulse is less than which rate?
Correct Answer: B
Rationale: For infants and young children, digoxin is withheld if the 1-minute apical pulse is below 90 beats/min to prevent toxicity. A rate of 60 is the adult threshold, and 100-120 beats/min are acceptable for administration.
Question 4 of 5
What clinical manifestation is a common sign of digoxin toxicity?
Correct Answer: B
Rationale: Vomiting, unrelated to feedings, is a common sign of digoxin toxicity due to its narrow therapeutic range. Seizures are not associated, bradycardia (not bradypnea or tachycardia) may occur, but vomiting is a key indicator.
Question 5 of 5
The parents of a young child with heart failure (HF) tell the nurse that they are nervous about giving digoxin. The nurses response should be based on which knowledge?
Correct Answer: D
Rationale: Digoxin?s narrow therapeutic range requires parents to learn specific guidelines for safe administration and monitoring to prevent toxicity. It?s not inherently safe, parents can be taught, and over- or undermedication is a risk without proper guidance.