A nurse is planning care for an 8-month-old infant who has heart failure. Which of the following actions should the nurse include in the plan of care?

Choice A Reason:

Increased expectoration is correct. Increased expectoration (coughing up and clearing mucus) could indicate improved airway clearance, which is a primary goal of chest physiotherapy in cystic fibrosis. Effective therapy would facilitate the removal of mucus from the airways, making it easier for the child to clear secretions.

Choice B Reason:

Reduced pain is incorrect. While reducing pain is important for overall comfort, chest physiotherapy's primary goal in cystic fibrosis is to improve airway clearance and lung function. Pain reduction might not be the primary indicator of the therapy's effectiveness in this context.

Choice C Reason:

Increased heart rate is incorrect. An increased heart rate might not directly indicate the effectiveness of chest physiotherapy for cystic fibrosis. The focus is primarily on improving respiratory function and airway clearance rather than affecting heart rate.

Choice D Reason:

Increased urine output is incorrect. Increased urine output is not typically a direct indicator of the effectiveness of chest physiotherapy in cystic fibrosis. Chest physiotherapy aims to improve respiratory function rather than affecting urine output.

A. "Check the pH of the gastric secretions."Checking the pH of the gastric secretions is crucial to confirm that the NG tube is correctly positioned in the stomach. This helps ensure that the tube is in the right place before administering the feeding, thereby reducing the risk of complications such as aspiration.

B. "Attach the feeding bag tubing to the end of the NG tube."Attaching the feeding bag tubing should be done after verifying the tube's placement and ensuring it is in the stomach. This step is important, but it follows confirmation of correct tube placement.

C. "Flush the tube with water."Flushing the tube with water is important to ensure patency and prepare the tube for feeding. However, this should only be done after confirming the tube's placement.

D. "Set the administration rate on the feeding pump."Setting the administration rate is necessary for administering the feeding but should be done after confirming tube placement and preparing the tube.