A nurse is assessing a 3-year-old child who has aortic stenosis.
Which of the following findings should the nurse expect?

Rationale for Correct Condition

Congestive heart failure (CHF) exacerbation is characterized by fluid overload leading to dyspnea, jugular vein distention, crackles, and rapid weight gain. The client’s worsening respiratory distress, bilateral lung crackles, tachypnea, and history of heart disease strongly indicate CHF rather than COPD exacerbation, pneumonia, or pneumothorax.

Rationale for Correct Actions

Elevating the head of the bed reduces pulmonary congestion by improving lung expansion and decreasing venous return, alleviating dyspnea. Applying oxygen at 6 L/min via nasal cannula enhances oxygenation by addressing hypoxia and improving tissue perfusion in the presence of pulmonary congestion.

Rationale for Correct Parameters

Oxygen saturation reflects pulmonary function and cardiac output, guiding oxygen therapy adjustments and determining hypoxia severity. Respiratory rate indicates the extent of respiratory distress, compensatory mechanisms for hypoxia, and the effectiveness of interventions.

Rationale for Incorrect Conditions

COPD exacerbation would typically involve wheezing, prolonged expiration, and severe airway obstruction. Pneumonia presents with fever, localized crackles, and productive cough, which are absent. Spontaneous pneumothorax causes sudden onset chest pain, absent breath sounds, and asymmetric lung expansion.

Rationale for Incorrect Actions

Smoking cessation program is beneficial long-term but does not address acute CHF symptoms. Asking about food intake is unrelated to managing pulmonary congestion. Applying oxygen at 2 L/min may not be sufficient for severe dyspnea; higher-flow oxygen is needed.

Rationale for Incorrect Parameters

WBC count monitors infection, which is not the primary concern in CHF. Temperature evaluates systemic infection, not fluid overload. Arterial blood gases provide respiratory status but are not routinely needed in CHF unless respiratory failure is suspected.

Choice A rationale

Acetaminophen is an appropriate analgesic for managing headaches, a common side effect of nitroglycerin due to vasodilation. It does not interfere with the therapeutic effects of nitroglycerin and provides symptomatic relief. Other non-steroidal anti-inflammatory drugs (NSAIDs) might be contraindicated in some cardiac patients, making acetaminophen a safer initial choice for headache management in this context.

Choice B rationale

Touching the medication portion of the transdermal patch can lead to unintended absorption of the nitroglycerin by the person applying it. This could result in side effects such as headache or hypotension in the caregiver. Maintaining the integrity of the dosage and preventing accidental exposure are crucial for safe medication administration.

Choice C rationale

Applying the nitroglycerin patch to a different site each day helps prevent skin irritation and sensitization at the application site. Consistent use on the same area can lead to local reactions, reduced absorption, and potential skin breakdown. Rotating sites ensures optimal drug absorption and minimizes dermatological complications.

Choice D rationale

Applying the nitroglycerin patch to hairy areas can impede proper adhesion to the skin, potentially affecting the absorption and efficacy of the medication. Hair can create a barrier, preventing consistent contact between the patch and the skin's surface, thus reducing the intended therapeutic effect.