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A 6-month-old infant with congestive heart
failure (CHF) is receiving digoxin elixir.
Which observation by the nurse warrants
immediate intervention?
Apical heart rate of 60.
Sweating across the forehead.
Doesn't suck well.
Respiratory rate of 30 breaths per minute.
Apical heart rate of 60.
A heart rate of 60 (A) is much lower than
normal for a 6-month-old and warrants
immediate intervention. The normal heart
,rate for a 6-month-old is 80 to 150 BPM
when awake, and a rate of 70 while
,sleeping is considered within normal limits.
(B and C) are expected symptoms of heart
failure in an infant. (D) is within normal
limits for an infant.
The nurse is teaching the parents of a 5-
year-old with cystic fibrosis about
respiratory treatments. Which statement
indicates to the nurse that the parents
understand?
Perform postural drainage before starting
aerosol therapy.
Give respiratory treatments when the child
is coughing a lot.
Administer aerosol therapy followed by
postural drainage before meals.
Ensure respiratory therapy is done daily
during any respiratory infection.
, Administer aerosol therapy followed by
postural drainage before meals.
Postural drainage for a child with cystic
fibrosis is most effective when performed
after nebulization and before meals (C) or at
least 1 hour after eating to prevent
nausea and vomiting. Postural drainage uses
gravity to promote mucous removal after
nebulization (A) treatments which open the
airways. Pulmonary toileting or respiratory
treatments should be given 3 to 4 times
daily, not episodically (B and D).
A female teenager is taking oral tetracycline
HCL (Achromycin V) for acne vulgaris. What
is the most important instruction for the
nurse to include in this client's teaching
plan?
Use sunscreen when lying by the pool.