A nurse is conducting discharge teaching to parents about the care of their infant after cardiac surgery. The nurse instructs the parents to notify the physician of what conditions occur. (Select all that apply.).
Respiratory rate of 36 breaths/minute at rest.
Appetite slowly increasing.
Temperature above 37.7° C (100° F).
New, frequent coughing.
Turning blue or bluer than normal.
Correct Answer : A,C,D,E
The correct answer is choices A, C, D, and E.
Choice A rationale:
A respiratory rate of 36 breaths/minute at rest is concerning in a pediatric client, as it may indicate respiratory distress or an underlying respiratory condition.
Choice B rationale:
An increasing appetite is generally a positive sign and not typically concerning unless accompanied by other symptoms.
Choice C rationale:
A temperature above 37.7° C (100° F) is concerning as it indicates fever, which could be a sign of infection or other medical conditions.
Choice D rationale:
New, frequent coughing is concerning as it may indicate respiratory infections, asthma, or other respiratory issues.
Choice E rationale:
Turning blue or bluer than normal (cyanosis) is a serious symptom indicating inadequate oxygenation and requires immediate medical attention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Drink a glass of water with a fat-free carbohydrate before getting out of bed in the morning. While staying hydrated is important, consuming a fat-free carbohydrate before getting out of bed may not be sufficient to alleviate nausea and vomiting. Eating small, frequent meals throughout the day, as suggested in choice B, can help stabilize blood sugar levels and prevent the stomach from becoming too empty, which can contribute to nausea.
Choice B rationale:
Eat small, frequent meals (every 2 to 3 hours). Eating small, frequent meals can help manage nausea and vomiting during pregnancy. Having something in the stomach at all times can prevent the stomach from becoming completely empty, reducing the likelihood of nausea. Additionally, choosing easily digestible foods can further alleviate symptoms.
Choice C rationale:
Increase her intake of high-fat foods to keep the stomach full and coated. Increasing intake of high-fat foods is not advisable, as they can be harder to digest and may exacerbate nausea. The focus should be on consuming small, low-fat, easily digestible meals throughout the day.
Choice D rationale:
Limit fluid intake throughout the day. Limiting fluid intake is not recommended, especially during pregnancy. It's important for pregnant women to stay hydrated. Dehydration can worsen nausea and may lead to other complications. Encouraging adequate fluid intake between meals can also help manage nausea.
Correct Answer is D
Explanation
Choice A rationale:
Explaining how SIDS could have been predicted and prevented might not be appropriate immediately after the loss, as it can come across as insensitive. The focus should be on providing emotional support to the grieving family.
Choice B rationale:
While it's essential to gather information about the circumstances surrounding the infant's death, conducting an in-depth interview immediately might be overwhelming for the parents. Sensitivity and timing are crucial in approaching this aspect of the situation.
Choice C rationale:
Discouraging parents from making a last visit with the infant is highly inappropriate and insensitive. Parents should be allowed to have their final moments with their children and say their goodbyes in a way that brings them comfort and closure.
Choice D rationale:
Making a follow-up home visit to parents as soon as possible after the infant's death is a crucial nursing responsibility. This visit provides an opportunity to offer emotional support, answer any questions the parents might have, and connect them with appropriate resources for coping with their loss. It demonstrates the nurse's ongoing commitment to the family's well-being during this challenging time.
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