A nurse is caring for a 2-month-old infant who has heart failure.
Which of the following actions should the nurse take?
Limit oral feedings to 30 min in length.
Weigh the infant every other day.
Place the infant in the prone position for naps.
Check the infant’s oxygen saturation every 6 hr.
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The Correct Answer is A
The correct answer is choice A. Limit oral feedings to 30 min in length.
This is because infants with heart failure have difficulty feeding and may become exhausted or dyspneic during prolonged feedings. By limiting the feeding time, the nurse can reduce the energy expenditure and caloric needs of the infant.
Choice B is wrong because weighing the infant every other day is not enough to monitor the fluid status and nutritional intake of the infant. The nurse should weigh the infant daily at the same time using the same scale.
Choice C is wrong because placing the infant in the prone position can compromise the respiratory function and increase the risk of sudden infant death syndrome (SIDS). The nurse should place the infant in a semi-Fowler’s position to facilitate breathing and decrease venous return.
Choice D is wrong because checking the infant’s oxygen saturation every 6 hr is not frequent enough to detect hypoxia or cyanosis. The nurse should monitor the oxygen saturation continuously or at least every 2 hr.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The correct answer is choice B. A client who is scheduled for a colonoscopy and is taking sodium phosphate requires follow-up care because sodium phosphate can cause colonic mucosal damage and electrolyte imbalances that may affect the safety and accuracy of the colonoscopy. Sodium phosphate is a bowel preparation agent that empties the colon before the procedure, but it can also cause dehydration, kidney injury, and cardiac arrhythmias.
Therefore, the nurse should monitor the client’s fluid intake, renal function, and serum electrolytes before and after the colonoscopy.
Choice A is wrong because a client who received a Mantoux test 48 hours ago and has an induration does not necessarily require follow-up care. A Mantoux test is a skin test that detects infection by Mycobacterium tuberculosis, the bacterium that causes tuberculosis (TB). The test involves injecting a small amount of tuberculin purified protein derivative (PPD) into the skin and measuring the size of the induration (firm swelling) after 48 to 72 hours. The interpretation of the test result depends on the size of the induration and the risk factors of the client for TB infection or disease. For example, an induration of 5 mm or more is considered positive in people living with HIV, recent contacts of infectious TB cases, or people with chest x-ray findings suggestive of previous TB disease. However, an induration of 15 mm or more is considered positive in people with no known risk factors for TB.
Therefore, the nurse should assess the client’s history and risk factors before determining whether the Mantoux test result requires follow-up care.
Choice C is wrong because a client who is taking bumetanide and has a potassium level of 3.6 mEq/L does not require follow-up care.
Bumetanide is a loop diuretic that lowers blood pressure by increasing urine output and reducing fluid retention. However, it can also cause hypokalemia (low potassium levels) as a side effect. The normal range for serum potassium is 3.5 to 5.0 mEq/L, so a level of 3.6 mEq/L is within the normal range and does not indicate hypokalemia.
Therefore, the nurse does not need to intervene for this client.
Correct Answer is A
Explanation
The correct answer is choice A. The nurse should ensure the state health department has been notified of the child’s Lyme disease, as it is a reportable disease in most states.
Reporting helps to monitor the incidence and prevalence of Lyme disease and to implement prevention and control measures.
Choice B is wrong because antitoxin is not used to treat Lyme disease.
Antitoxin is a substance that neutralizes the effects of a toxin, such as botulism or tetanus. Lyme disease is caused by a bacterium called Borrelia burgdorferi, which can be treated with antibiotics.
Choice C is wrong because Lyme disease is not transmitted by sharing personal belongings. Lyme disease is spread to humans by the bite of infected ticks that carry the
bacterium. The risk of getting Lyme disease can be reduced by avoiding tick-infested areas, wearing protective clothing, using insect repellent, and removing ticks promptly.
Choice D is wrong because skin necrosis is not a common complication of Lyme disease.
Skin necrosis is the death of skin tissue due to lack of blood supply or infection. Lyme disease can cause a characteristic skin rash called erythema migrans, which is usually circular or oval and expands over time. Other possible signs and symptoms of Lyme disease include fever, headache, fatigue, joint pain, and neurological problems.
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