A nurse is caring for a child who is postoperative following surgical correction of Tetralogy of Fallot. Which of the following findings should the nurse identify as an indication of heart failure?

Weight loss

Decreased respirations

Exercise intolerance

Bradycardia

Answer and Explanation

The Correct Answer is C

Choice A reason: Weight loss is not typically an indication of heart failure. In fact, patients with heart failure may experience weight gain due to fluid retention.

Choice B reason: Decreased respirations are not a common sign of heart failure. Instead, heart failure can cause increased respiratory rate and effort due to fluid accumulation in the lungs.

Choice C reason: Exercise intolerance, or difficulty in engaging in physical activity, is a classic symptom of heart failure. It occurs due to the heart's inability to pump enough blood to meet the body's demands during exercise.

Choice D reason: Bradycardia, or a slower than normal heart rate, is not a direct indication of heart failure. While it can be associated with certain cardiac conditions, it is not a specific sign of heart failure.

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Correct Answer is C

Explanation

Choice A reason: Applying lotion to the skin under the straps is not recommended as it can interfere with the harness's grip and may lead to slippage or improper positioning.

Choice B reason: Expecting the baby to wear the harness for only 2 weeks may be incorrect as the duration of use is typically determined by the physician based on the infant's progress and may extend beyond 2 weeks.

Choice C reason: Placing the diaper under the straps is correct as it allows for easy diaper changes without removing the harness and ensures that the harness remains in the proper position.

Choice D reason: Adjusting the straps daily is not advised unless instructed by a healthcare professional. Improper adjustments can affect the effectiveness of the harness and the treatment of developmental dysplasia of the hip.

A. Obtain written consent from the client. B. Contact the client's parents to obtain phone consent. C. Postpone the testing until the client's parents are present. D. Request verbal consent from the social worker.

Correct Answer is A

Explanation

Choice A reason: Obtaining written consent from the client is appropriate as adolescents are entitled to confidential care for STIs. This respects the client's autonomy and privacy.

Choice B reason: Contacting the client's parents may not be necessary unless the adolescent is under the age specified by law for independent consent. It could also breach confidentiality.

Choice C reason: Postponing the testing could delay diagnosis and treatment, which is not in the best interest of the client. Immediate testing is important for health and well-being.

Choice D reason: Requesting verbal consent from the social worker is not appropriate as the consent should come directly from the client or their legal guardian, if required.

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A nurse is caring for a child who is postoperative following surgical correction of Tetralogy of Fallot. Which of the following findings should the nurse identify as an indication of heart failure?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

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Correct Answer is A

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