A nurse teaches the parents of a 4-year-old child who is to receive digoxin (Lanoxin) elixir at home about the basic principles regarding its administration. What statement indicates to the nurse that they need further teaching?a. 'We'll brush his teeth after each dose.'b. 'We won't mix the digoxin with fluids and foods.'c. 'We shouldn't give an additional dose if he vomits.' d. 'We should give the digoxin twice a day, at breakfast and dinner.'

1. A nurse teaches the parents of a 4-year-old child who is to receive digoxin (Lanoxin) elixir at home about the basic principles regarding its administration. What statement indicates to the nurse that they need further teaching?

a. 'We'll brush his teeth after each dose.'

b. 'We won't mix the digoxin with fluids and foods.'

c. 'We shouldn't give an additional dose if he vomits.'

d. 'We should give the digoxin twice a day, at breakfast and dinner.'

D!

Doses given at breakfast and dinner will not be spaced equally; the child should be given digoxin (Lanoxin) at 12-hour intervals. The sweetened elixir may cause tooth decay; it should be directed to the side and back of the mouth and the teeth should be brushed after each administration. Digoxin should be given on an empty stomach 1 hour before a meal or 2 hours after. Some of the medication may be absorbed before the child vomits, so a second dose could result in an overdose.
C!

Weight reduction decreases intraabdominal pressure, thereby decreasing the tendency to reflux into the esophagus. Fats decrease emptying of the stomach, extending the period that reflux can occur; fats should be decreased. Lying down after eating increases the pressure against the diaphragmatic hernia, increasing symptoms. Drinking several glasses of fluid during each meal will increase the pressure; fluid should be discouraged with meals.

B!

A stage II pressure ulcer is a partial-thickness ulceration of epidermis or dermis; it presents as an abrasion, blister, or shallow crater, has a red/pink wound bed, has no tissue sloughing, and may have an intact/open serum filled blister. A stage I ulcer has tissue injury with a purple or maroon localized area of intact skin or blood-filled blister; the area may be firm, boggy, warmer, cooler, or painful in comparison with nearby tissue. A stage III pressure ulcer has full-thickness ulceration involving the epidermis, dermis, and subcutaneous tissue; sloughing may be present, it presents as a deep crater with or without undermining, and bone, tendon, or muscle are not exposed. A stage IV pressure ulcer involves full-thickness skin loss and damage to muscle, bone, or tendon; sloughing or eschar may be present on parts of the wound bed, and it often includes undermining and tunneling.
B!

Rhonchi are coarse sounds heard over the larger airways; including rhonchi in the record makes the documentation inaccurate. Crackles and rhonchi are clinical indicators, not a nursing diagnosis. It is incorrect to use the term rhonchi to refer to crackling sounds in the lower lung. Crepitus, which indicates subcutaneous emphysema, is unrelated to auscultated breath sounds.