An infant is receiving digoxin (Lanoxin) for congestive heart failure. The baby’s apical heart rate is assessed at 80 beats/minute. What intervention should the nurse implement?

Correct Answer: B

Rationale: The correct answer is B: Obtain a therapeutic drug level. The rationale for this is that digoxin has a narrow therapeutic range, and monitoring drug levels is crucial to prevent toxicity or subtherapeutic effects. By obtaining a drug level, the nurse can ensure that the infant is receiving the appropriate dose. A: Calling for a portable chest radiograph is not necessary for assessing the infant's heart rate in this scenario. C: Reassessing the heart rate in 30 minutes does not address the need to confirm the drug level for proper dosing. D: Administering digoxin immune Fab (Digibind) stat is a drastic measure for digoxin toxicity, which is not indicated based solely on the heart rate assessment at this time.

Correct Answer: B

Rationale: The correct answer is B because vaccination involves prior exposure to an infectious agent in an attenuated or weakened form. This exposure triggers the immune system to produce antibodies and memory cells, providing immunity against future infections. Choice A is incorrect as deliberately introducing a virulent strain can lead to severe disease instead of prevention. Choice C is incorrect as antibiotics are used to treat bacterial infections, not prevent viral diseases like vaccines. Choice D is incorrect as vaccines primarily stimulate adaptive immune responses, not innate immune responses.

Correct Answer: D

Rationale: The correct answer is D: infection. Neutrophils are a type of white blood cell responsible for fighting off infections. A low neutrophil count puts the client at risk for developing infections as their body's ability to fight off pathogens is compromised. Anemia (choice A) is related to low red blood cells, not white blood cells like neutrophils. Blood clots (choice B) and hemorrhage (choice C) are more related to platelets and clotting factors, not neutrophil count. Therefore, the correct answer is D as the primary concern with neutropenia is the increased susceptibility to infections.

Correct Answer: A

Rationale: The correct answer is A: Multiple blood transfusions. Receiving multiple blood transfusions increases the risk of developing antibodies against donor blood, leading to transfusion reactions. Iron-deficiency anemia (B) and low RBC count (D) are conditions that may necessitate blood transfusions but do not inherently increase the risk of transfusion reactions. Completing a cross and match blood test (C) is a standard procedure to ensure compatibility and reduce the risk of reactions, thus it does not increase the risk of a transfusion reaction.

Correct Answer: A

Rationale: The correct answer is A: Dependent edema. In right-sided heart failure, the weakened right ventricle fails to effectively pump blood, leading to fluid retention and congestion in the systemic circulation. This results in dependent edema, typically seen in the lower extremities. Pulmonary crackles (B) are associated with left-sided heart failure due to fluid accumulation in the lungs. Shortness of breath (C) is a common symptom of both left-sided and right-sided heart failure. Chest pain (D) is not a typical finding in right-sided heart failure unless there is an underlying cause such as myocardial infarction.