A nurse is caring for a 2-month-old infant who has heart failure. Which of the following actions should the nurse take?
Limit oral feedings to 30 min in length.
Weigh the infant every other day.
Place the infant in the prone position for naps.
Check the infant’s oxygen saturation every 6 hr.
The Correct Answer is A
This is because infants with heart failure have difficulty feeding and may become exhausted or dyspneic during prolonged feedings. By limiting the feeding time, the nurse can reduce the energy expenditure and caloric needs of the infant.
Choice B is wrong because weighing the infant every other day is not enough to monitor the fluid status and nutritional intake of the infant. The nurse should weigh the infant daily at the same time using the same scale.
Choice C is wrong because placing the infant in a prone position can compromise respiratory function and increase the risk of sudden infant death syndrome (SIDS). The nurse should place the infant in a semi-Fowler’s position to facilitate breathing and decrease venous return.
Choice D is wrong because checking the infant’s oxygen saturation every 6 hr is not frequent enough to detect hypoxia or cyanosis. The nurse should monitor the oxygen saturation continuously or at least every 2 hr.
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Correct Answer is D
Explanation
This action helps the client feel more comfortable and less intimidated by the nurse. It also allows the nurse to observe the client’s swallowing and signs of aspiration more easily.
Choice A is wrong because talking with the client during her feeding can distract her from swallowing properly and increase the risk of aspiration.
The nurse should encourage the client to focus on eating and avoid conversation until the feeding is over.
Choice B is wrong because discouraging the client from coughing during feedings can prevent her from clearing her airway and expelling any food particles that might have entered the trachea.
The nurse should monitor the client for coughing, choking, or changes in voice quality, which are indicators of aspiration.
Choice C is wrong because instructing the client to lift her chin when swallowing can actually make swallowing more difficult and increase the risk of aspiration.
The nurse should instruct the client to tuck her chin when swallowing, which helps close off the trachea and direct food into the esophagus.
Correct Answer is B
Explanation
Exercise can help stimulate bowel movements and prevent constipation, which is a common side effect of opioid medications. Exercise can also improve blood circulation, reduce stress, and enhance mood, which can benefit clients who have chronic pain.
Choice A is wrong because decreasing insoluble fiber intake can worsen constipation. Insoluble fiber adds bulk to the stool and helps it pass more easily through the colon.
Clients who take opioid medications should increase their intake of insoluble fiber from sources such as whole grains, fruits, vegetables, nuts, and seeds.
Choice C is wrong because drinking less water can lead to dehydration and hardening of the stool, which can make it more difficult to pass.
Clients who take opioid medications should drink plenty of water to keep the stool soft and moist.
Choice D is wrong because taking a laxative every day can cause dependence, tolerance, and electrolyte imbalance.
Laxatives should be used only as a last resort and under the guidance of a health care provider.
Clients who take opioid medications should try other methods of preventing constipation first, such as increasing exercise, fiber, and water intake.
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