Which intervention should be included in the plan of care for an infant with the nursing diagnosis of Excess Fluid Volume related to congestive heart failure?
Weigh the infant every day on the same scale at the same time.
Notify the physician when weight gain exceeds more than 20 g/day.
Put the infant in a car seat to minimize movement.
Administer digoxin as ordered by the physician.
The Correct Answer is D
Digoxin is a medication that helps improve the pumping function of the heart and reduces fluid retention in the lungs and other tissues. It is commonly used to treat congestive heart failure in infants.
Choice A is wrong because weighing the infant every day on the same scale at the same time is a way to monitor fluid balance, not an intervention to treat excess fluid volume.
Choice B is wrong because notifying the physician when weight gain exceeds more than 20 g/day is also a monitoring measure, not an intervention. Moreover, weight gain may not accurately reflect fluid volume status in some patients with heart failure due to poor nutrition and decreased appetite.
Choice C is wrong because putting the infant in a car seat to minimize movement may worsen the respiratory distress and increase the workload of the heart. The infant should be positioned in a semi-Fowler’s or Fowler’s position to facilitate breathing and reduce venous return.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Children with asthma who are taking long-term inhaled steroids should be assessed frequently to monitor for this increased risk because some studies have shown a growth delay in children treated with moderate to high doses of inhaled steroids. This appears to occur only during the first year of treatment and may be reversible.
Choice A is wrong because cough is not a side effect of inhaled steroids, but a symptom of asthma itself.
Choice B is wrong because osteoporosis is not a common side effect of inhaled steroids in children, but a possible risk for adults who use high doses of inhaled steroids or oral steroids.
Choice D is wrong because Cushing’s syndrome is not a side effect of inhaled steroids, but a rare complication of oral steroids.
Correct Answer is D
Explanation
Ulcerative colitis is a chronic inflammatory bowel disease that causes diarrhea, pain, and bleeding in the colon. Stress and certain foods can trigger or worsen the symptoms, so it is important to teach the mother how to help her son cope with stress and avoid triggers.
Choice A is wrong because ulcerative colitis is not an infectious disease that can spread to others.
Choice B is wrong because ulcerative colitis causes diarrhea, not constipation. Nutritional guidance is important, but not the main focus of teaching.
Choice C is wrong because the daily use of enemas is not part of the treatment plan for ulcerative colitis. Enemas can irritate the colon and cause more inflammation.
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