A 4-month-old child taking digoxin (Lanoxin) has a blood pressure of 92/78; resting pulse of 78; respirations 28, and a potassium level of 4.8 mEq/L. The client is irritable and has vomited twice since the morning dose of digoxin. Which finding is most indicative of digoxin toxicity?

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Question 1 of 5

A 4-month-old child taking digoxin (Lanoxin) has a blood pressure of 92/78; resting pulse of 78; respirations 28, and a potassium level of 4.8 mEq/L. The client is irritable and has vomited twice since the morning dose of digoxin. Which finding is most indicative of digoxin toxicity?

Correct Answer: A

Rationale: Bradycardia (abnormally slow heart rate) is a key sign of digoxin toxicity. In this scenario, the child's symptoms of irritability, vomiting, along with the resting pulse of 78 despite being on digoxin, suggest an impending bradycardia due to digoxin toxicity. Lethargy can also be a sign, but in this case, the child is irritable rather than lethargic. Vomiting, though a symptom, is not as specific to digoxin toxicity as bradycardia. Irritability, while present, is not the most indicative finding of digoxin toxicity compared to bradycardia.

Question 2 of 5

A client with chronic congestive heart failure should be instructed to contact the home health nurse if which finding occurs?

Correct Answer: A

Rationale: A rapid weight gain of 2 pounds or more in a 48-hour period may indicate fluid retention and worsening heart failure, requiring prompt medical evaluation and intervention. This finding is crucial in managing chronic congestive heart failure as it signifies a potential exacerbation of the condition. Choices B, C, and D are less concerning in this context. Urinating 4 to 5 times a day is within the normal range for most individuals and may not be directly related to heart failure. A significant decrease in appetite may be due to various factors and might not be an immediate cause for concern in heart failure patients. The appearance of non-pitting ankle edema, although related to heart failure, is a more chronic and less urgent symptom when compared to a rapid weight gain, which requires immediate attention.

Question 3 of 5

When the nurse identifies what appears to be ventricular tachycardia on the cardiac monitor of a client being evaluated for possible myocardial infarction, the first action the nurse should perform is to

Correct Answer: D

Rationale: The correct first action for the nurse to take when identifying what appears to be ventricular tachycardia in a client being evaluated for possible myocardial infarction is to assess the client's airway, breathing, and circulation. This step is crucial to determine the client's stability and the need for immediate intervention. Beginning cardiopulmonary resuscitation or preparing for immediate defibrillation without first assessing the airway, breathing, and circulation could delay potentially life-saving interventions. Notifying the 'Code' team and healthcare provider should come after ensuring the client's immediate needs are addressed.

Question 4 of 5

A client is scheduled to have a blood test for cholesterol and triglycerides the next day. The nurse would tell the client

Correct Answer: B

Rationale: Fasting for at least 12 hours is necessary before a cholesterol and triglyceride test to ensure accurate results by avoiding fluctuations that can occur after eating. Choice A is incorrect because a fat-free diet is not required; fasting is. Choice C is incorrect as it suggests having the test right after eating, which can affect the results. Choice D is incorrect as there is no need to stay at the laboratory for 2 blood samples unless specifically instructed by a healthcare provider.

Question 5 of 5

When caring for premature newborns in an intensive care setting, a nurse carefully monitors oxygen concentration. What is the most common complication of this therapy?

Correct Answer: B

Rationale: Retinopathy of prematurity is the most common complication in premature infants exposed to high concentrations of oxygen. This condition leads to abnormal blood vessel growth in the retina, which can potentially result in blindness if not managed promptly. Intraventricular hemorrhage, though a significant concern in premature infants, is not directly related to oxygen therapy. Bronchopulmonary dysplasia is primarily associated with mechanical ventilation and oxygen exposure over time, not specifically with oxygen concentration monitoring. Necrotizing enterocolitis is more linked to gastrointestinal issues and is not the most common complication of oxygen therapy in premature newborns.

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