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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Comparing the client’s current weight with preprocedure weight is the best way to evaluate the effectiveness of the paracentesis, which is a procedure to remove excess fluid from the abdominal cavity. The fluid buildup, or ascites, is a common complication of end-stage liver disease (ESLD), which is a condition in which the liver is severely damaged and cannot function adequately.
Choice B is wrong because examining for leakage at the site of the procedure is not a measure of effectiveness, but a potential complication that should be monitored and reported.
Choice C is wrong because checking the client’s serum albumin levels is not relevant to the paracentesis.
Albumin is a protein that helps maintain fluid balance in the body, but it is not affected by the removal of fluid from the abdomen.
Choice D is wrong because confirming that the client is able to urinate is not related to the paracentesis.
Urination is a function of the kidneys, not the liver, and it does not reflect the amount of fluid removed from the abdomen.
Correct Answer is B
Explanation
A hematoma is a collection of blood outside a blood vessel that can cause swelling, pain, and bruising. It can indicate bleeding from the artery where the catheter was inserted, which can be a serious complication of cardiac catheterization.
The nurse should notify the provider immediately if a hematoma is observed.
Choice A is wrong because a heart rate of 90/min is within the normal range for adults and does not indicate a complication.
Choice C is wrong because bounding pulses in the affected extremity are expected after cardiac catheterization, as they indicate good blood flow to the area.
Choice D is wrong because the report of discomfort at the insertion site is common and usually mild after cardiac catheterization.
The nurse can provide pain relief as needed but does not need to notify the provider unless the pain is severe or persistent.
Normal ranges for heart rate are 60-100 beats per minute for adults. Normal ranges for blood pressure are 120/80 mmHg or lower for systolic pressure and 80 mmHg or lower for diastolic pressure. Normal ranges for oxygen saturation are 95-100% for adults.
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