Page 1082 - Saunders Comprehensive Review For NCLEX-RN

364. Answer: 3

Rationale: Kawasaki disease, also known as mucocutaneous lymph node syndrome, is
an acute systemic inflammatory illness. In the acute stage, the child has a fever,
conjunctival hyperemia, red throat, swollen hands, rash, and enlargement of the
cervical lymph nodes. In the subacute stage, cracking lips and fissures,
desquamation of the skin on the tips of the fingers and toes, joint pain, cardiac
manifestations, and thrombocytosis occur. In the convalescent stage, the child
appears normal, but signs of inflammation may be present.
Test-Taking Strategy: Focus on the subject, the acute stage of Kawasaki disease.
Option 2 can be eliminated first, because a normal appearance is not likely in the
acute stage. From the remaining options, focusing on the words acute stage in the
question will assist in directing you to the correct option.
Level of Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process—Assessment
Content Area: Pediatrics: Cardiovascular
Health Problem: Pediatric-Specific: Kawasaki Disease
Priority Concepts: Clinical Judgment; Inflammation
Reference: McKinney et al. (2018), p. 1111.

365. Answer: 4

Rationale: Digoxin is a cardiac glycoside. The parents need to be instructed that if
the child vomits after digoxin is administered, they are not to repeat the dose.
Options 1, 2, and 3 are accurate instructions regarding the administration of this
medication. In addition, the parents should be instructed that if a dose is missed and
is not identified until 4 hours later, the dose should not be administered.
Test-Taking Strategy: Note the strategic words, need for further instruction. These
words indicate a negative event query and ask you to select an option that is an
incorrect statement. General knowledge regarding digoxin administration will assist
in eliminating option 2. Principles related to administering medications to children
will assist in eliminating option 1. From the remaining options, select the correct
option because if the child vomits, it would be difficult to determine whether the
medication also was vomited or was absorbed by the body.
Level of Cognitive Ability: Evaluating
Client Needs: Physiological Integrity
Integrated Process: Teaching and Learning
Content Area: Pediatrics: Cardiovascular
Health Problem: Pediatric-Specific: Congestive Heart Failure
Priority Concepts: Client Education; Safety
Reference: McKinney et al. (2018), p. 1087.

366. Answer: 1

Rationale: Heart failure is the inability of the heart to pump a sufficient amount of
blood to meet the oxygen and metabolic needs of the body. The most appropriate

1082