Difficulty: Medium
Average Score: 69%
Simulated
Passage / Scenario
Received 4-year-old child with an exacerbation of heart failure. Family reports history of congenital mitral stenosis. Breath sounds with wheezing noted in bilateral lower lobes. Nonproductive cough noted. Dyspnea with respiratory rate 30/min. Oxygen at 2 L/min applied per nasal cannula. Telemetry applied: Sinus rhythm a rate 116/min. Abdomen soft, nontender. Bowel sounds positive all 4 quadrants. Lower extremities with 2+ edema noted. Pedal pulses palpable bilaterally. Peripheral saline lock intact to right forearm with no signs and symptoms of infection. Weight 20 kg (44 lb). Increase in dyspnea noted with orthopnea. Nasal flaring with respiratory rate of 36/min. Lung sounds with wheezing noted throughout. Lower extremity edema 3+ to bilateral lower extremities. Extremities cool with decreased skin pigmentation noted. Peripheral pulses weak bilateral jugular vein distention noted.The client is at risk for developing ____ and ____
Correct answer
A,B
Rationale
The client is at risk for developing digitalis toxicity due to the use of digitalis medications, which can lead to adverse effects on the heart. Hypokalemia is also a risk due to the potassium-wasting effects of digitalis. Other choices are incorrect as they do not directly relate to the client's risk factors in this scenario. Therefore, choices C to G can be eliminated as they are not relevant to the client's condition and medication regimen.