Patient Data

Exhibits

Review H and P, nurse's notes, and laboratory results.

Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress,

Answer and Explanation

The Correct Answer is []

Potential condition: Polycythemia

Actions to take

Have the parents increase the child's caloric intake: Polycythemia in children with tetralogy of Fallot can be managed by ensuring adequate hydration and nutrition. Increasing caloric intake helps support growth and development and can prevent excessive erythrocytosis.

Take the child's vital signs: Regular monitoring of vital signs, including heart rate, respiratory rate, blood pressure, and temperature, is essential to assess the child's cardiovascular status and response to treatment.

Parameters to monitor

Oxygen saturation: Monitoring oxygen saturation helps assess the adequacy of pulmonary blood flow and oxygenation in a child with tetralogy of Fallot and polycythemia.

Weight: Monitoring weight is crucial to assess growth and nutritional status. Children with tetralogy of Fallot may have poor weight gain due to increased metabolic demands and potential feeding difficulties.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Correct Answer is ["B","C"]

Explanation

Rationale

A. High in sodium due to pickling, which is not suitable for someone with hypertension.

B. Recommended because fresh fruits are low in sodium and high in potassium and other nutrients beneficial for managing blood pressure.

C. Recommended because they are low in sodium and rich in potassium, fiber, and nutrients that support cardiovascular health.

D. Cottage cheese is high in sodium and should be avoided or consumed in moderation.

E. Generally high in sodium, which should be limited or avoided in the diet of someone with hypertension.

A. A bedside commode is positioned near the bed. B. The client is lying in a supine position in bed. C. A low sodium diet tray was brought to the room. D. A full pitcher of water is on the bedside table. E. A saline lock is present in the right forearm.

Correct Answer is ["B","D"]

Explanation

Rationale

A. This is generally a good practice for clients who may have difficulty ambulating to the bathroom due to their condition. It promotes safety and reduces the risk of falls, especially during episodes of dyspnea.

B. A supine position can increase venous return to the heart and exacerbate symptoms of heart failure by increasing preload. This can lead to increased pulmonary congestion and respiratory distress. Therefore, this observation requires immediate intervention.

C. Providing a low sodium diet aligns with managing heart failure by reducing fluid retention and workload on the heart. This observation does not require immediate intervention unless there are specific dietary restrictions or concerns.

D. In heart failure, fluid restriction is often necessary to prevent fluid overload and exacerbation of symptoms. Having a full pitcher of water accessible to the client could lead to excessive fluid intake, which is concerning and requires immediate intervention.

E. A saline lock allows access for intravenous medications or fluids if needed. Its presence does not necessarily indicate a need for immediate intervention unless it is not functioning properly or if there are signs of infection or infiltration.

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Actions to take

Parameters to monitor

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When conducting diet teaching for a client who was diagnosed with hypertension, which food(s) should the nurse encourage the client to eat? Select all that apply.

Correct Answer is ["B","C"]

Explanation

A client is admitted with an exacerbation of heart failure secondary to chronic obstructive pulmonary disease (COPD). Which observation(s) by the nurse require immediate intervention to reduce the likelihood of harm to this client? Select all that apply.

Correct Answer is ["B","D"]

Explanation

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