A nurse is assisting with the care of an infant who has heart failure. Which of the following actions should the nurse take?
Place the infant in a supine position during naps.
Feed the infant a bottle every 4 hr.
Document the infant's respiratory rate every 2 hr.
Withhold digoxin if the infant's heart rate is greater than 100/min.
The Correct Answer is C
Choice A rationale:
Placing the infant in a supine position during naps might not be the best action for an infant with heart failure. In heart failure, infants often experience difficulty breathing due to fluid accumulation in the lungs. Placing the infant in a more upright position, such as semi-Fowler's, can help alleviate some of this respiratory distress.
Choice B rationale:
Feeding the infant a bottle every 4 hours is important, but it might not directly address the immediate concerns of an infant with heart failure. Infants with heart failure might have difficulty feeding due to fatigue and respiratory distress. Feeding smaller, more frequent meals and assessing the infant's feeding tolerance is crucial.
Choice C rationale:
Correct Answer. Documenting the infant's respiratory rate every 2 hours is an important action. Infants with heart failure often have respiratory distress and an increased respiratory rate, as the body tries to compensate for decreased cardiac output. Documenting the respiratory rate will help the healthcare team monitor the infant's condition and assess the effectiveness of interventions.
Choice D rationale:
Withholding digoxin if the infant's heart rate is greater than 100/min is not necessarily the correct action. Digoxin is a medication commonly used in heart failure to improve cardiac contractility. While it's important to monitor the infant's heart rate, a heart rate of greater than 100/min might be due to the body's compensatory mechanisms in response to heart failure. Withholding the medication without consulting a healthcare provider might not be appropriate.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Adolescents are at a stage of development where body image and appearance are of significant importance. Discussing how the procedure might affect the client's appearance allows the nurse to address the adolescent's concerns and fears related to changes in their body. This can help alleviate anxiety and promote a sense of control over the situation, fostering a more positive psychological response to the surgery.
Choice B rationale:
Avoiding involving the client in decisions regarding treatment (Choice B) would not be appropriate for an adolescent. Adolescents are at a stage where they are developing autonomy and decision-making skills. Excluding them from decisions about their treatment could lead to feelings of powerlessness and hinder their sense of control.
Choice C rationale:
Emphasizing that the procedure is not a punishment (Choice C) might be suitable for younger children who might associate medical procedures with punishment. However, adolescents typically do not perceive medical procedures as punishments, so this explanation may not address their specific concerns.
Choice D rationale:
Keeping equipment out of the client's sight (Choice D) might be more relevant for younger children who might be frightened by medical equipment. Adolescents are generally better able to comprehend and cope with the presence of medical equipment. Open communication about the procedure and addressing their concerns directly would be more beneficial.
Correct Answer is B
Explanation
Choice A rationale:
Administer pain medication. Administering pain medication is important for the preschooler's comfort, but it is not the nurse's priority action in this scenario. The priority is to ensure adequate circulation to the extremities, which can be assessed by checking capillary refill.
Choice B rationale:
Check capillary refill. This is the correct answer because the nurse's priority is to assess the child's circulation and tissue perfusion. In 90-90 traction, there is a risk of impaired circulation to the extremities due to the positioning. Checking capillary refill provides information about the adequacy of blood flow to the capillaries and is crucial for early detection of any circulation problems.
Choice C rationale:
Cleanse and dress the pin sites. While caring for the pin sites is important to prevent infection, it is not the priority action at this moment. Ensuring proper circulation and perfusion takes precedence over pin site care.
Choice D rationale:
Reposition the child every 2 hr. Repositioning the child is important to prevent complications associated with immobility, but it is not the nurse's priority action in this situation. The primary concern is to assess and address any circulation issues.
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