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Questions 158

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Question 1 of 5

A 19-month-old child is admitted to the hospital for surgical repair of patent ductus arteriosus. The child is being given digoxin. Prior to administering the medication, the nurse should:

Correct Answer: C

Rationale: Digoxin should not be given to adults with an apical pulse <60 bpm. Digoxin should be given to children with an apical pulse >100 bpm. With a pulse <100 bpm, the medication should be withheld and the physician notified. Prior to digoxin administration in both children and adults, an apical pulse should be taken for 1 full minute. Aside from the rate per minute, the nurse should note any sudden increase or decrease in heart rate, irregular rhythm, or regularization of a chronic irregular heart rhythm. Early indications of digoxin toxicity, such as visual disturbances, occur rarely as initial signs in children.

Question 2 of 5

When assessing the client with acute arterial occlusion, the nurse would expect to find:

Correct Answer: B

Rationale: Acute arterial occlusion causes ischemia, leading to tissue necrosis, which may present as minute blackened areas on the toes, indicating severe ischemia.

Question 3 of 5

The client is admitted with a diagnosis of molar pregnancy. Which intervention is most appropriate?

Correct Answer: A

Rationale: Molar pregnancy involves abnormal trophoblastic tissue and no viable fetus often causing vaginal bleeding. Monitoring for bleeding is critical.
Tocolytics cesarean delivery and fetal monitoring are not indicated.

Question 4 of 5

The nurse is caring for a client with a history of a fractured pelvis who is in skeletal traction. The nurse should:

Correct Answer: D

Rationale: Monitoring for infection at pin sites prevents osteomyelitis in skeletal traction. Turning is limited, weights must hang freely, and lotion is unnecessary.

Question 5 of 5

Which statement is true regarding therapy with Levemir (insulin detemir)?

Correct Answer: D

Rationale: Levemir (insulin detemir) is a long-acting insulin with a duration of up to 24 hours, used for basal coverage. Its onset is 1–2 hours, but it has no distinct peak, and it should not be mixed with other insulins.

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