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.
(Ans- 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. (Ans- 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.
Cleanse the skin at least 4 times a day.
Take the medication with a glass of milk.
Menstrual periods may become irregular.
(Ans- Use sunscreen when lying by the pool.
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