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.

Answer and Explanation

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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is A

Explanation

This is because continuous enteral feedings through an NG tube can increase the risk of aspiration, which is the inhalation of food or fluids into the lungs. Measuring gastric residual volumes (GRV) can help monitor the tolerance and absorption of the feedings and prevent overfeeding. GRV is the amount of fluid aspirated from the stomach via an enteral tube to check for gastric emptying. The normal range of GRV is less than 200 ml.

Choice B is wrong because advancing the rate of the feeding every 2 hr can lead to overfeeding, abdominal distension, nausea, vomiting and diarrhea.

The rate of the feeding should be adjusted according to the client’s nutritional needs and tolerance.

Choice C is wrong because maintaining the head of the bed at a 20° angle is not enough to prevent aspiration. The head of the bed should be elevated at least 30° to 45° during and for at least one hour after feeding.

Choice D is wrong because flushing the NG tube with 30 mL 0.9% sodium chloride before and after medication is not related to continuous enteral feedings. This is a practice to prevent clogging of the tube and ensure proper delivery of medication. Flushing the tube with water before and after feeding is also recommended to maintain patency and hydration.

A. Nonreactive pupils. B. Serpentine limb movement. C. Smacking lips. D. Shuffling gait.

Correct Answer is D

Explanation

This is because shuffling gait is a common manifestation of pseudo-parkinsonism, which is a condition that mimics the symptoms of Parkinson’s disease due to the use of certain medications that block dopamine receptors, such as haloperidol. Pseudoparkinsonism can cause slowed movements, muscle stiffness, tremor, and postural instability.
Choice A. Nonreactive pupils are wrong because this is not a typical feature of pseudoparkinsonism or Parkinson’s disease.
Nonreactive pupils can be caused by other conditions, such as brain injury, drugs, or eye diseases.
Choice B. Serpentine limb movement is wrong because this is a characteristic of tardive dyskinesia, another drug-induced movement disorder that can result from the long-term use of dopamine receptor-blocking agents. Tardive dyskinesia causes involuntary movements of the face, tongue, and limbs that are often writhing or twisting.
Choice C. Smacking lips is wrong because this is also a sign of tardive dyskinesia, not pseudo-parkinsonism. Smacking lips is one of the orofacial movements that can occur in tardive dyskinesia due to abnormal muscle contractions.

View Question and Answer

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

A nurse is caring for a 2-month-old infant who has heart failure. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning care for a client who has a prescription for continuous enteral feedings through an NG tube. Which of the following actions should the nurse plan to take?

Correct Answer is A

Explanation

A nurse is assessing a client who is taking haloperidol and is experiencing pseudo-parkinsonism. Which of the following findings should the nurse document as a manifestation of pseudoparkinsonism?

Correct Answer is D

Explanation

A nurse is preparing to obtain a health history from a client who is on bedrest. Which of the following positions should the nurse take to place the client at ease?

A nurse is providing discharge teaching to a client who is postoperative following surgery for carpal tunnel syndrome. Which of the following statements by the client indicates an understanding of the teaching?

A home health nurse is caring for a child who has Lyme disease. Which of the following is an appropriate action for the nurse to take?

A nurse is preparing to administer vancomycin IV to an adult client. The client asks the nurse if the medication can be given 2 hr earlier. Which of the following statements should the nurse make?

A nurse is caring for a client who is experiencing expressive aphasia and right hemiparesis following a stroke. Which of the following actions by the nurse best promotes communication among staff caring for the client?

A staff nurse is observing a newly licensed nurse suction a client’s tracheostomy. Which of the following actions by the newly licensed nurse requires intervention by the staff nurse?

A school nurse is teaching a parent about absence seizures. Which of the following information should the nurse include?

A nurse is setting up a sterile field to perform wound irrigation for a client. Which of the following actions should the nurse take when pouring the sterile solution?