A nurse is caring for a pediatric patient with congestive heart failure (CHF). What major goal should the nurse include in the care of this patient?
Prevent contractures of his hips and knees.
Minimize his cardiac output.
Minimize his energy expenditure.
Prevent vomiting.
The Correct Answer is C
Choice A rationale:
Preventing contractures of the hips and knees is not directly related to the care of a pediatric patient with congestive heart failure (CHF). CHF primarily involves impaired cardiac function and fluid retention, not joint contractures.
Choice B rationale:
Minimizing cardiac output would be counterproductive in the care of a patient with CHF. The goal is to optimize cardiac output to meet the body's demands while managing the symptoms of CHF.
Choice C rationale:
Minimizing energy expenditure is a major goal in the care of a pediatric patient with CHF. CHF places an extra workload on the heart, and conserving energy helps prevent additional strain on the heart, allowing it to function more efficiently.
Choice D rationale:
Preventing vomiting is not a specific goal related to the care of a pediatric patient with CHF. Vomiting might be a symptom of CHF, but the primary focus is on managing cardiac function and fluid balance.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Planning for nurses to provide feedings is not necessary since this is not related to the nursing care plan and doesn't address the mother's concern.
Choice B rationale:
Reporting the finding to the health care provider is appropriate because vomiting after surgical repair of hypertrophic pyloric stenosis could indicate a potential complication or issue.
Choice C rationale:
Assuring the mother that vomiting after surgical repair is normal might not be accurate and could dismiss a potentially significant concern.
Choice D rationale:
Telling the mother it is all right to feel anxious doesn't address the vomiting concern directly and might not be the most pertinent response at this time.
Correct Answer is A
Explanation
"I will take the enzymes with all my meals and snacks.”.
Choice A rationale:
Taking pancreatic enzymes with all meals and snacks is the correct approach. Pancreatic enzymes are essential for aiding digestion and should be taken whenever food is consumed to ensure proper nutrient absorption.
Choice B rationale:
Taking enzymes only with meals is insufficient. Snacks also require enzyme supplementation for effective digestion.
Choice C rationale:
Waiting for complications before taking enzymes is incorrect. Enzymes are necessary for every meal and snack to prevent malabsorption and digestive issues.
Choice D rationale:
Taking enzymes at night before bed is not recommended. Enzymes are needed when food is present in the stomach, which typically occurs during meals and snacks, not before bedtime.
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