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.

Answer and Explanation

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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Correct Answer is D

Explanation

The most important action for the PN to implement is to **assess the vital signs**. Saturation of a peripad within 15 minutes to 1 hour after delivery must be promptly reported. Data such as the amount of bleeding, the condition of the uterus, checking the maternal vital signs, and observing for signs of shock would play a vital role in the care of the patient with hemorrhage¹. Early recognition and treatment of PPH are critical to care management.

A. Delay administration of nighttime medications until after visitors have left. B. Administer a prescribed PRN benzodiazepine at the onset of a confused state. C. Make certain that the client's assigned room is close to the nurses' station. D. Ask family members about how they dealt with the client in the evening.

Correct Answer is C

Explanation

Restlessness, confusion, and agitation are common symptoms of dementia, particularly in the evening, a phenomenon known as sundowning. Therefore, the PN should implement interventions that can help to prevent or minimize these symptoms. Assigning the client to a room close to the nurses' station can help to provide constant observation and reassurance and can help to prevent the client from wandering or becoming disoriented.
A. Delaying administration of nighttime medications until after visitors have left may be appropriate, but it is not the first intervention to be implemented in this scenario.
B. Administering a prescribed PRN benzodiazepine at the onset of a confused state may be appropriate in some cases, but it should not be the first intervention to be implemented in this scenario.
D. Asking family members about how they dealt with the client in the evening may be helpful, but it is not the first intervention to be implemented in this scenario.

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The practical nurse (PN) is planning care for a child with heart failure. Which intervention should the PN give the greatest priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is C

Explanation

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