The nurse is preparing to administer a dose of digoxin (Lanoxin) to a child in heart failure (HF). Which is a beneficial effect of administering digoxin (Lanoxin)?

Correct Answer: A

Rationale: Digoxin is a medication commonly used in the treatment of heart failure (HF) because of its positive inotropic effect, which means it strengthens the heart muscle. While digoxin does not directly decrease edema, its ability to increase the strength of the heart muscle allows the heart to pump more effectively. When the heart is pumping blood more efficiently, it can help reduce fluid accumulation in the body, including edema.

Correct Answer: D

Rationale: Tetralogy of Fallot is a congenital heart defect characterized by four primary abnormalities: pulmonary stenosis, ventricular septal defect, overriding aorta, and right ventricular hypertrophy. Due to the pulmonary stenosis, less blood reaches the lungs to be oxygenated, resulting in deoxygenated blood entering the systemic arterial circulation. This leads to cyanosis, which is often referred to as "Tet spells" in these patients. Cyanosis is the bluish discoloration of the skin and mucous membranes caused by the presence of deoxygenated hemoglobin. The other conditions listed do not typically result in deoxygenated blood entering the systemic arterial circulation and causing cyanosis.

Correct Answer: C

Rationale: When a child is admitted to the hospital with dehydration and a urinary tract infection (UTI), the urinalysis result that the nurse should expect is an increased white blood cell (WBC) count, indicated by WBC >2, along with a slightly elevated specific gravity, typically around 1.016. A specific gravity of 1.016 suggests some concentration of urine due to dehydration, while an increased WBC count indicates the presence of infection in the urinary tract. These findings are consistent with dehydration and UTI in a preschool child. Options A, B, and D do not fully align with the expected urinalysis results in this clinical scenario.

Correct Answer: A

Rationale: With a WBC count of 3,000/ul (indicating leukopenia or low white blood cell count), the priority nursing intervention should be preventing infection. Leukopenia puts the client at a higher risk of developing infections due to a compromised immune system. Nurses should focus on implementing strict infection control measures, such as hand hygiene, maintaining a sterile environment, and promoting vaccination compliance to reduce the risk of infection for the hospitalized client. This intervention is crucial for ensuring the client's safety and well-being during their hospital stay. Alleviating pain, controlling infection, and monitoring blood transfusion reactions are important aspects of care but in this scenario, preventing infection takes precedence due to the client's low WBC count.

Correct Answer: A

Rationale: Monitoring a patient's weight is a crucial assessment in heart failure management. Sudden weight gain could indicate fluid retention, which is a common sign of worsening heart failure. By regularly monitoring the patient's weight, the nurse can detect early signs of fluid buildup and adjust the treatment plan accordingly. Weight monitoring is a simple yet effective way to assess the severity of heart failure and prevent complications. The other options (B. Appetite, C. Calorie count, D. Abdominal girth) are not as directly related to monitoring heart failure severity as weight measurement.