A nurse is applying soft limb restraints to a child who is acting aggressively toward staff. Which of the following actions should the nurse take?

Tie the restraints to the side rails of the child's bed.

Request that the provider renew the prescription for restraints every 48 hr.

Secure the restraints with a quick-release knot.

Assess the child every 4 hr while in restraints.

Answer and Explanation

The Correct Answer is C

A.   Tying restraints to the side rails poses a risk of injury to the child and is not a recommended practice.
B.   Renewing the prescription for restraints every 48 hours is important, but it does not directly address the proper application of restraints.
C.   Securing restraints with a quick-release knot allows for quick removal in case of emergency and is the correct method for applying restraints.
D.   Assessing the child every 4 hours while in restraints is important, but it does not address the proper application of restraints.

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Correct Answer is C

Explanation

A. Allowing the infant to self-soothe by crying prior to feeding is not appropriate, as it may lead to increased stress and fatigue, which can worsen heart failure symptoms.

B. Placing the infant in an upright position during feeding helps to reduce the risk of aspiration and promotes effective swallowing.

C. Infants with heart failure have a weakened heart that struggles to pump blood efficiently. Feeding can be tiring for them, and they might not be able to consume large volumes at once. A smaller, more frequent feeding schedule allows them to take in enough calories without overexertion. This approach helps manage their energy expenditure and reduces stress on the heart.

D. While some infants might take longer to feed, heart failure can make feeding tiring. Offering smaller, more frequent feedings can help the infant consume enough calories without expending too much energy.

A. An increase in potassium levels B. A decrease in peripheral edema C. A decrease in cardiac output D. An increase in venous pressure

Correct Answer is B

Explanation

A. Furosemide is a loop diuretic that typically causes potassium loss, so an increase in potassium levels would not be expected as an indication of effectiveness.
B. Furosemide is prescribed to reduce fluid volume overload, which often manifests as peripheral edema in patients with heart failure. A decrease in peripheral edema indicates that the medication is effectively reducing fluid retention.
C. Furosemide is not typically prescribed to decrease cardiac output but rather to reduce fluid volume overload, which may help improve cardiac function indirectly.
D. Furosemide is not typically prescribed to increase venous pressure but rather to decrease fluid volume overload, which may help reduce venous pressure over time.

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A nurse is applying soft limb restraints to a child who is acting aggressively toward staff. Which of the following actions should the nurse take?

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Naxlex Comprehensive Predictor Exams

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