A nurse is caring for a 2-month-old infant who has heart failure and is receiving furosemide.
Which of the following findings is the nurse's priority?
Negative doll's eye reflex
Sunken anterior fontanel
Potassium 5.1 mEq/L
Heart rate 162/min
The Correct Answer is D
A. Negative doll's eye reflex (also known as oculocephalic reflex) is a normal finding in infants. It is a reflexive movement of the eyes in the opposite direction of the head
movement.
B. A sunken anterior fontanel can indicate dehydration, which is a concern. However, in a 2-month-old with heart failure, a high heart rate (tachycardia) may indicate worsening of the heart failure and needs to be addressed promptly.
C. A potassium level of 5.1 mEq/L is within the normal range for infants. While electrolyte balance is important, it is not the priority in this situation.
D. This is the correct answer. A heart rate of 162/min in a 2-month-old infant with heart failure is elevated and requires immediate attention. It may indicate worsening heart
failure or an adverse reaction to the medication (furosemide) being administered. The nurse should assess the infant's condition, notify the healthcare provider, and intervene as necessary.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Applying warming blankets is important for maintaining the child's body temperature, but it is not the top priority in this situation.
B. Administering an IV bolus may be necessary, but it is not the priority action. The child's airway and breathing take precedence.
C. This is the correct action. In cases of submersion injury, there is a risk of respiratory distress or failure due to aspiration of water. Assisting with intubation helps ensure a patent airway and adequate oxygenation.
D. Obtaining an arterial blood gas (ABG) sample is an important assessment, but it is not the top priority. Ensuring a patent airway and providing adequate oxygenation come first.
Correct Answer is B
Explanation
A. Unexplained weight gain is not a typical finding in Hodgkin's lymphoma. Weight loss is more commonly associated with this condition.
B. Night sweats are a common symptom of Hodgkin's lymphoma. They can be indicative of the body's response to the cancer.
C. Flushed skin is not typically associated with Hodgkin's lymphoma. Pallor or jaundice may be more commonly observed.
D. Decreased body temperature is not a typical finding in Hodgkin's lymphoma. Infection or fever may lead to an elevated body temperature.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.