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 B
Explanation
The correct answer is choice B. A client who is 1 day postoperative following a vertebroplasty. A vertebroplasty is a procedure that injects cement into a fractured vertebra to help relieve pain and stabilize the spine. The recovery time for this procedure is usually short and the complications are rare.
Therefore, this client is most likely to be stable and ready for early discharge.
Choice A is wrong because a client who is receiving heparin for deep-vein thrombosis (DVT) needs close monitoring of their blood levels and clotting factors. Heparin is a blood thinner that prevents the clots from getting bigger or breaking loose and traveling to the lungs, which can cause a life-threatening condition called pulmonary embolism (PE).
This client is not a good candidate for early discharge.
Choice C is wrong because a client who has cancer and a sealed implant for radiation therapy needs to be isolated in a special room to prevent exposure of others to radiation. A sealed implant is a small holder that contains a radioactive source that is placed inside or near the tumor to deliver high doses of radiation. This type of internal radiation therapy, also called brachytherapy, can last from several minutes to several days, depending on the type and dose of the radioactive source.
This client is not a good candidate for early discharge.
Choice D is wrong because a client who has COPD and a respiratory rate of 44/min has signs of respiratory distress and possible hypoxemia (low oxygen levels in the blood).
COP
Correct Answer is A
Explanation
The correct answer is Choice A.
Choice A rationale:
- Acknowledges the client's feelings:It's important for the nurse to validate the client's concerns and let them know that it's understandable to feel nervous or uncertain about ECT.
- Provides information about the treatment:The nurse can offer information about the potential benefits of ECT,but it's important not to pressure the client or make them feel like they have to go through with it.
- Reassures the client of their right to change their mind:This is a crucial aspect of informed consent.The client has the right to withdraw their consent at any time,even after signing the consent form.
Choice B rationale:
- Places undue pressure on the client:This response implies that the doctor knows what's best for the client and that the client should go through with the treatment even if they have doubts.This can undermine the client's autonomy and decision-making ability.
Choice C rationale:
- May minimize the client's concerns:While rescheduling the treatment is an option,it's important to explore the client's concerns more thoroughly before suggesting this.It's possible that the client has valid reasons for not wanting to go through with ECT,and these reasons should be addressed.
Choice D rationale:
- Is disrespectful of the client's autonomy:This response suggests that the client is obligated to go through with the treatment simply because they signed a consent form.This ignores the fact that people can change their minds and that consent is an ongoing process.
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