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 C
Explanation
Choice A reason: Clear liquids are not the best intervention for acute diarrhea and dehydration in children. Clear liquids are fluids that are transparent or translucent, such as water, broth, tea, or juice. They may provide some hydration, but they do not contain enough electrolytes (sodium, potassium, chloride) to replace the losses from diarrhea. They may also worsen diarrhea by increasing the osmotic load in the gut.
Choice B reason: Absorbents such as kaolin and pectin are not recommended for acute diarrhea and dehydration in children. Absorbents are substances that bind to toxins, bacteria, or water in the gut, and are supposed to reduce the frequency and volume of stools. However, there is no evidence that they are effective or safe for children with diarrhea. They may also interfere with the absorption of other medications or nutrients.
Choice C reason: Oral rehydration solution (ORS) is the preferred intervention for acute diarrhea and dehydration in children. ORS is a specially formulated solution that contains water, glucose, and electrolytes in the right proportions to replenish the losses from diarrhea. ORS can prevent or treat dehydration, and can also reduce the duration and severity of diarrhea. ORS is widely available, inexpensive, and easy to use. It should be given to children with diarrhea as soon as possible, and continued until the diarrhea stops.
Choice D reason: Antidiarrheal medications are not advised for acute diarrhea and dehydration in children. Antidiarrheal medications are drugs that slow down the movement of the gut, reduce the secretion of fluids, or kill the bacteria that cause diarrhea. However, they are not effective for viral diarrhea, which is the most common cause of diarrhea in children. They may also have serious side effects, such as constipation, abdominal pain, drowsiness, or allergic reactions. They may also mask the symptoms of more serious conditions, such as appendicitis or bowel obstruction.
Correct Answer is D
Explanation
Choice A reason: This statement does not best illustrate the developmental stage of an eighteen-year-old. Getting an A in a math exam is an academic achievement, but it does not reflect the psychosocial development of the individual.
Choice B reason: This statement does not best illustrate the developmental stage of an eighteen-year-old. Going to a senior prom is a social event, but it does not indicate the identity or role of the individual.
Choice C reason: This statement does not best illustrate the developmental stage of an eighteen-year-old. Having conflicts with parents is a common issue among adolescents, but it does not show the maturity or independence of the individual.
Choice D reason: This statement best illustrates the developmental stage of an eighteen-year-old. Going to college to become a nurse is a decision that reflects the individual's identity, career, and future goals. It also shows the individual's ability to plan ahead, make choices, and take responsibility for their life.
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