The parents of a young child with heart failure tell the nurse that they are "nervous" about giving digoxin (Lanoxin). The nurse's response should be based on which statement?

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Question 1 of 5

The parents of a young child with heart failure tell the nurse that they are "nervous" about giving digoxin (Lanoxin). The nurse's response should be based on which statement?

Correct Answer: A

Rationale: The correct response is option A. By reassuring the parents that digoxin is a safe and frequently used drug, the nurse can help alleviate their concerns about administering the medication to their child. This approach fosters trust and confidence in the treatment plan. It is essential for the nurse to provide accurate information to help the parents feel more comfortable and confident in caring for their child.

Question 2 of 5

A client is undergoing peritoneal dialysis. Which of the ff is a major complication of the procedure that the nurse should monitor for?

Correct Answer: D

Rationale: Peritonitis is a major complication of peritoneal dialysis that the nurse should monitor for. Peritonitis is an infection of the peritoneum, the membrane that lines the abdominal cavity and covers the abdominal organs. It can occur when bacteria from the dialysis solution enter the peritoneal cavity. Symptoms of peritonitis may include abdominal pain, cloudy dialysis effluent, fever, and general signs of infection. Prompt recognition and treatment of peritonitis are crucial to prevent complications such as sepsis and peritoneal membrane damage. Regular monitoring and strict aseptic technique during peritoneal dialysis can help reduce the risk of peritonitis.

Question 3 of 5

A 36 y.o. woman who has had no prenatal care comes into the hospital in active labor for her fourth child. She has vesicles evident on her perineum. The following nursing actions are appropriate to protect the unborn baby and the staff, EXCEPT:

Correct Answer: D

Rationale: When a woman with vesicles on her perineum comes into the hospital in active labor, it is important to take precautions to protect the unborn baby and the staff. However, applying antibiotic ointment to the vesicles and placing the mother in reverse isolation is not appropriate in this situation. This is because her condition is most likely due to herpes simplex virus (HSV) infection, which can be transmitted to the baby during birth leading to severe complications. Placing the mother in reverse isolation can increase the risk of transmission to the healthcare staff as well. Instead, notifying the obstetrician and nurse midwife about the vesicles as soon as possible is crucial for proper management and preparing for the possibility that the baby may be delivered by cesarean section is important to reduce the risk of transmission during vaginal birth. Maintaining standard precautions is essential to prevent the spread of infection.

Question 4 of 5

Management of the foregoing patient should include:

Correct Answer: C

Rationale: The patient's symptoms of muscle weakness and fatigue are likely due to hypermagnesemia, which is an excess of magnesium in the blood. Hence, the management should include discontinuing any oral magnesium salts that the patient may be taking. This will help in correcting the magnesium imbalance and improving the patient's symptoms. Regular diet modifications and potassium-sparing diuretics are not indicated for the treatment of hypermagnesemia and may not address the underlying cause in this case.

Question 5 of 5

The nurse, in assessing the adequacy of a client's fluid replacement during the first 2 to 3 days following full- thickness burns to the trunk and right thigh, would be aware that the most significant data would be obtained from recording

Correct Answer: C

Rationale: Monitoring urinary output every hour is crucial in assessing the adequacy of fluid replacement in a client with full-thickness burns. Burn injuries can result in a significant loss of fluid and electrolytes due to increased capillary permeability and excessive fluid shift from the intravascular space to the interstitial space. Adequate fluid replacement is essential to maintain tissue perfusion, prevent hypovolemia, and support organ function. By closely monitoring the urinary output every hour, the nurse can assess renal perfusion, fluid balance, and the effectiveness of fluid resuscitation. A decrease in urinary output can indicate inadequate fluid replacement, while an increase may suggest fluid overload. This information is important in guiding adjustments to the fluid replacement therapy to ensure optimal outcomes for the client. Weights, blood pressure measurements, and assessment of peripheral edema are also important data to monitor in a burn client, but urinary output is the most significant indicator of fluid balance in

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