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

Limit oral feedings to about 30 minutes in length

Check the infant’s oxygen saturation every 6 hours

Weigh the infant every other day

Place the infant in the prone position for naps

Answer and Explanation

The Correct Answer is A

A. Correct – Infants with heart failure experience fatigue during feeding, leading to poor weight gain. Limiting feeding time reduces energy expenditure.
B. Incorrect – Oxygen saturation should be checked more frequently than every 6 hours, especially if the infant has cyanosis or respiratory distress.
C. Incorrect – Daily weight monitoring is necessary to assess fluid status and nutritional intake.
D. Incorrect – The infant should be placed on their back for naps to prevent sudden infant death syndrome (SIDS).

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Correct Answer is B

Explanation

A. A metallic taste is not a common adverse effect of sertraline.
B. Sertraline, a selective serotonin reuptake inhibitor (SSRI), commonly causes excessive sweating as an adverse effect.
C. A dry cough is more often related to ACE inhibitors than SSRIs.
D. Increased urinary frequency is not typically associated with sertraline.

A. Temperature B. Potassium level C. WBC count D. Blood pressure E. Breath sounds

Correct Answer is ["A","C","E"]

Explanation

A. Temperature (38.6°C / 101.5°F): A fever in a chemotherapy client with a low WBC count is concerning for infection or neutropenic fever, which can be life-threatening. Neutropenia (WBC 3,800/mm³) weakens the immune response, making infections more severe.
B. Potassium level (3.6 mEq/L): The potassium level is within normal limits (3.5–5.0 mEq/L) and does not indicate an immediate concern.
C. WBC count (3,800/mm³): The client's WBC count has dropped significantly from 8,000/mm³ to 3,800/mm³, indicating chemotherapy-induced neutropenia. A low WBC count increases the risk of infection and warrants further assessment and precautions.
D. Blood pressure (114/56 mmHg): The blood pressure is within an acceptable range and does not indicate hypotension or other hemodynamic instability.
E. Breath sounds (Crackles at lung bases): New crackles at the lung bases suggest a potential respiratory infection (e.g., pneumonia), which is especially concerning in neutropenic clients. The presence of fever and tachypnea (respiratory rate 24/min) further supports possible infection.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing teaching to a client about the adverse effects of sertraline. Which of the following adverse effects should the nurse include

Correct Answer is B

Explanation

A nurse is caring for a client Exhibits A nurse is reviewing the client's electronic medical record. Which of the following findings require follow up? Select all that apply.

Correct Answer is ["A","C","E"]

Explanation

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