The practical nurse (PN) is planning care for a child with heart failure. Which intervention should the PN give the greatest priority?
Monitor therapeutic level of phenytoin.
Increase fluid intake.
Cluster care to conserve the child's energy.
Restrict intake of foods high in sugar.
The Correct Answer is C
For a child with heart failure, the greatest priority for the practical nurse (PN) is to conserve the child's energy. Clustered care activities and rest periods will help to conserve the child's energy and minimize the workload on the heart.
Monitoring therapeutic levels of phenytoin (A) is not relevant to the care of a child with heart failure. Increasing fluid intake (B) is not a priority intervention for a child with heart failure, as excessive fluid intake can worsen heart failure. Restricting intake of foods high in sugar (D) may be necessary for a child with heart failure, but it is not the greatest priority for the PN to address.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The best response for the PN to provide is that **an immunization may be administered for hepatitis B, and a consent form must be signed**. Phytonadione is a form of vitamin K that is given to newborns to prevent vitamin K deficiency bleeding (VKDB)¹. Vitamin K should be administered to all newborn infants weighing>1500 g as a single, intramuscular dose of 1 mg within 6 hours of birth¹. However, this is not the only injection your baby may receive while in the newborn nursery. An immunization for hepatitis B may also be administered before you can go home⁴.
Correct Answer is D
Explanation
Encouraging the client to initiate daily rituals, such as practicing relaxation techniques, engaging in physical exercise, and spending time with friends and family, can be an effective way to diminish anxiety. These activities can provide a sense of structure and routine that can help to manage stress and anxiety. Options A and C are not recommended because alcohol and caffeine can worsen sleeplessness and anxiety. Option B can be counterproductive and increase the client's anxiety level. Therefore, Option D is the best option to assist this client in diminishing his anxiety.
Therefore, options A, B, and C are not answers because they are not the best action to assist this client in diminishing his anxiety.
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