A nurse is caring for a 6-week-old infant.
The Correct Answer is []
Condition Most Likely Experiencing: C
Actions to Take: A, B
Parameters to Monitor: B, C
Rationale:
Condition Most Likely Experiencing
A. Pyloric stenosis causes projectile vomiting, dehydration, and hunger.
B. Cystic fibrosis causes chronic respiratory infections, steatorrhea, and failure to thrive.
C. The condition that the infant is most likely experiencing is congestive heart failure, which can cause poor weight gain, tachypnea, decreased appetite, and periorbital edema.
D. Respiratory syncytial virus bronchiolitis causes wheezing, coughing, and respiratory distress.
Actions to Take
A. Digoxin is a medication commonly prescribed to manage congestive heart failure in infants by improving cardiac contractility and reducing heart rate.
B. Elevating the head of the bed helps reduce venous return to the heart, thereby decreasing preload and relieving symptoms of congestion in congestive heart failure.
C. Contact precautions are not indicated for congestive heart failure, but for infections that are transmitted by direct or indirect contact.
D. Chest physiotherapy and postural drainage are not indicated for congestive heart failure, but for conditions that cause excessive mucus production and retention.
Parameters to Monitor
A. Number of steatorrhea stools is not relevant for congestive heart failure, but for cystic fibrosis or other malabsorption disorders.
B. Monitoring intake and output is crucial in assessing fluid balance, especially in congestive heart failure where fluid retention can lead to volume overload.
C. Monitoring respiratory status is essential in congestive heart failure to assess for signs of pulmonary congestion and respiratory distress, such as tachypnea, retractions, and crackles.
D. Presence of periorbital edema is not a parameter to monitor, but a sign of fluid overload.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Impetigo is highly contagious, and contact isolation precautions are necessary to prevent its spread to other patients and healthcare providers.
B. Reporting impetigo contagiosa to the state health department is typically not required unless there is an outbreak, as it is a localized skin infection.
C. Amphotericin B is used for fungal infections, not bacterial skin infections like impetigo. Antibiotics are required for treatment.
D. Lidocaine ointment is used for pain relief but is not indicated for treating impetigo. Antibiotic treatment is required for the condition.
Correct Answer is C
Explanation
A. Cleansing the perineum with povidone-iodine is not necessary for a routine urine collection. It might be required for specific procedures but not for a 24-hour collection.
B. The final specimen should be included in the 24-hour urine collection, not saved separately.
C. The first voided specimen should be discarded at the start of a 24-hour urine collection to ensure that the urine collection represents the entire 24-hour period.
D. Voiding every hour is not required. The key is to collect urine over the entire 24-hour period.
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