As a result of opioid administration, a child's respirations are slow and shallow. Which should the nurse anticipate when assessing the child's arterial blood gas?

Correct Answer: A

Rationale: When a child's respirations are slow and shallow due to opioid administration, it results in hypoventilation. This leads to retaining carbon dioxide, indicated by an increased PCO2 level on arterial blood gas analysis, and subsequently causes respiratory acidosis due to the buildup of CO2 in the blood.

Correct Answer: C

Rationale: When a patient is prescribed verapamil and digoxin, it is crucial to monitor for signs of digoxin toxicity due to the potential interaction between these medications. Verapamil can elevate digoxin blood serum levels, increasing the risk of toxicity. Symptoms of digoxin toxicity include nausea, vomiting, and visual changes. Restricting intake of oral fluids and high-fiber foods is not a specific consideration related to this medication combination. Before administering digoxin, it is essential to take an apical pulse for a full minute, not just 30 seconds. Additionally, holding the medications if the heart rate exceeds 110 bpm is not a typical response to the combination of verapamil and digoxin, which can cause bradycardia rather than tachycardia.

Correct Answer: D

Rationale: In the context of pediatric nursing and the administration of warfarin, a low INR of 1.2 indicates that the patient's blood is not adequately anticoagulated, putting them at risk for clot formation. The most appropriate action by the nurse is to call the healthcare provider to increase the dose of warfarin. This is because the current dose is not achieving the desired therapeutic effect, and an adjustment is needed to reach the target INR range. Option A, administering IV push protamine sulfate, is incorrect as protamine sulfate is used to reverse the effects of heparin, not warfarin. Continuing with the current prescription (Option B) would not address the subtherapeutic INR level. Option C, preparing to administer Vitamin K, is not the first-line intervention for a low INR in a patient taking warfarin; it is typically reserved for cases of warfarin overdose or when there is excessive anticoagulation leading to bleeding. In a pediatric nursing context, it is crucial to understand the appropriate actions to take when managing anticoagulation therapy in children to ensure their safety and well-being. Monitoring and adjusting warfarin doses based on INR levels are essential components of pediatric nursing care to prevent complications such as thrombosis or bleeding events.

Correct Answer: A

Rationale: The correct action for the nurse to take in this scenario is to give instructions on relieving symptoms with acetaminophen (Option A). This is the appropriate response because the symptoms described by the parent - local soreness, erythema, lethargy, and a low-grade fever - are common and expected side effects following a vaccine administration, particularly the MMR vaccine. These symptoms are typically mild and can be managed with supportive care, such as acetaminophen for fever and discomfort. Option B, seeking emergency help for signs of anaphylactic reaction, is incorrect in this case as the symptoms presented are not indicative of a severe allergic reaction. Option C is also incorrect as it provides inaccurate information about live vaccines causing a mild case of measles, which is not true for the MMR vaccine. Option D, filling out a Vaccine Adverse Event Report form, is not necessary at this point as the symptoms are within the expected range for a vaccine reaction and do not warrant reporting as an adverse event. From an educational perspective, it's important for nurses to be able to differentiate between common, mild vaccine reactions and more serious adverse events. Understanding the expected side effects of vaccines and how to manage them is crucial in providing safe and effective care to pediatric patients. Nurses should also be able to educate parents about normal post-vaccination symptoms and when to seek further medical attention.

Correct Answer: D

Rationale: The correct answer is D: BP of 70/50. When sildenafil (Viagra) is taken with nitroglycerin, it can cause severe hypotension that is unresponsive to treatment. The combination of these medications can lead to a dangerous drop in blood pressure. It is crucial to immediately report hypotension in this scenario. It is recommended to allow at least 24 hours to elapse between the last dose of sildenafil and nitroglycerin to prevent such adverse effects. The other vital signs and lab values may be abnormal but do not have the immediate life-threatening implications that severe hypotension does in this context.