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 B

Explanation

The priority goal for the practical nurse (PN) in the antepartum clinic is to ensure that the client recognizes the dangers of alcohol use during pregnancy. Alcohol consumption during pregnancy can lead to fetal alcohol syndrome and other developmental disorders. It is important for the client to understand the risks associated with alcohol use and to avoid it during pregnancy. The other goals are also important but recognizing the dangers of alcohol use takes priority.

A. Support the client's upper body and knees with pillows. B. Encourage the client to push with the next contraction. C. Assist the team to prepare for a possible cesarean delivery. D. Gently wrap the cord with a dry sterile dressing.

Correct Answer is C

Explanation

The umbilical cord prolapse is an emergency situation that requires immediate intervention. The PN should not attempt to push the cord back into the vagina or cover it with a dry sterile dressing. Instead, the PN should notify the healthcare provider and the obstetrical team and assist in preparing for an emergency cesarean delivery.

Option A and B may be appropriate in some situations, but they are not the priority in this scenario.

Therefore, options A, B, and D are not answers because they do not address the immediate emergency of umbilical cord prolapse.

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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

The practical nurse (PN) notes several nutritional goals in a standardized plan of care used in the antepartum clinic. Which client goal takes priority?

Correct Answer is B

Explanation

The practical nurse (PN) is assigned to assist in the care of a laboring client at 42-weeks gestation. While providing perineal care, the PN observes the umbilical cord protruding from the vagina. Which action should the PN take?

Correct Answer is C

Explanation

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