A four-month-old infant is hospitalized for repair of a ventricular septal defect. The infant's admitting diagnosis is moderate congestive heart failure. If the infant's CHF worsens, the nurse may implement which of the following interventions, assuming an order was written?
Make patient NPO
Administer diuretics
Administer antipyretics
Provide IV bolus
The Correct Answer is B
Choice A reason: Making the patient NPO (nothing by mouth) is not an appropriate intervention for CHF. NPO status may be indicated for other reasons, such as before surgery or certain tests, but it does not address the fluid overload or poor cardiac function that causes CHF.
Choice B reason: Administering diuretics is a common and effective intervention for CHF. Diuretics help reduce the excess fluid in the body and lungs, which improves breathing and lowers blood pressure. Diuretics also decrease the workload of the heart and prevent further damage to the cardiac muscles.
Choice C reason: Administering antipyretics is not a specific intervention for CHF. Antipyretics are used to lower fever, which may or may not be present in CHF. Fever may indicate an infection, which can worsen CHF, but antipyretics alone do not treat the underlying cause of the infection or the CHF.
Choice D reason: Providing IV bolus is not a recommended intervention for CHF. IV bolus is a rapid infusion of fluid or medication into the bloodstream. This may increase the fluid volume and pressure in the body and lungs, which can exacerbate CHF and cause pulmonary edema. IV bolus may be used for other conditions, such as hypovolemic shock or dehydration, but not for CHF.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Surgery is the definitive treatment for hypertrophic pyloric stenosis, which is a condition in which the muscle of the pylorus (the outlet of the stomach) becomes thickened and blocks the passage of food into the small intestine. The surgery, called pyloromyotomy, involves cutting the muscle to widen the opening and allow food to pass through. The surgery is usually done laparoscopically, with small incisions and a camera, and has a high success rate and low complication rate¹.
Choice B reason: Dietary restrictions are not required throughout childhood for infants with hypertrophic pyloric stenosis. After the surgery, the infant can resume normal feeding, usually within a few hours or days. The infant may have some vomiting or spitting up for a short period, but this usually resolves without any special diet.
Choice C reason: Slow feeding is not a necessary intervention for infants with hypertrophic pyloric stenosis. Slow feeding may help reduce the amount of vomiting, but it does not address the underlying problem of the pyloric obstruction. Slow feeding may also cause the infant to become frustrated, hungry, or tired. The infant should be fed according to his or her appetite and cues, and burped frequently to prevent air swallowing.
Choice D reason: Chromosomal mutation is not the cause of hypertrophic pyloric stenosis. The exact cause of this condition is unknown, but it is likely influenced by both genetic and environmental factors. Some studies have found an association between hypertrophic pyloric stenosis and certain genes, but no single gene mutation has been identified as the cause. Other risk factors include being male, firstborn, premature, exposed to certain antibiotics, or having a family history of the condition².
Correct Answer is B
Explanation
Choice A reason: This is not the correct cause, as varicella is a viral infection that causes a blister-like rash all over the body, not just in the diaper area. Varicella also causes fever, headache, and malaise.
Choice B reason: This is the correct cause, as Candida albicans is a type of fungus that can cause diaper rash, especially after antibiotic use. Antibiotics can disrupt the normal flora of the skin and allow the fungus to grow. Candida albicans causes red, inflamed skin with small, raised bumps around the edges.
Choice C reason: This is not the correct cause, as impetigo is a bacterial infection that causes honey-colored crusts on the skin, usually around the mouth and nose. Impetigo is contagious and can spread to other parts of the body or other people.
Choice D reason: This is not the correct cause, as bacterial infection is too vague and nonspecific. Bacterial infection can cause different types of skin rashes, depending on the type and location of the bacteria. Bacterial infection may also cause other symptoms, such as fever, pus, or swelling.
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