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 C
Explanation
- . Answer and explanation.
The correct answer is choice C, first-degree atrioventricular block.
This is because the PR interval is longer than normal, which indicates a delay in the conduction of electrical impulses from the atria to the ventricles through the AV node. A normal PR interval is 0.12 to 0.2 seconds, or 3 to 5 small squares on the EKG strip.
In this case, the PR interval is 0.35 seconds, which is more than 5 small squares.
Choice A is wrong because atrial fibrillation is a type of arrhythmia where the atria beat irregularly and rapidly, producing chaotic and variable P waves and an irregular ventricular response.
There is no constant PR interval in atrial fibrillation.
Choice B is wrong because complete heart block is a type of arrhythmia where there is no conduction of electrical impulses from the atria to the ventricles, resulting in independent and dissociated atrial and ventricular rhythms.
There are no consistent P waves or PR intervals in complete heart block.
Choice D is wrong because premature atrial complexes are extra beats that originate from the atria and interrupt the normal sinus rhythm.
They produce abnormal P waves that are different from the sinus P waves, and may have a shorter or longer PR interval depending on the timing of the impulse.
However, they do not cause a constant prolongation of the PR interval.
Correct Answer is B
Explanation
Choice A reason:
Ketorolac is incorrect because it is an NSAID that is used for short-term pain relief. It has a higher risk of causing irritation to the stomach lining and is not recommended for clients with a history of peptic ulcers.
Choice B reason:
Acetaminophen is the correct answer. When caring for a client who reports a headache and has a history of a peptic ulcer, the nurse should administer Acetaminophen. Acetaminophen is an analgesic (pain reliever) and antipyretic (fever reducer) that does not have anti-inflammatory properties. It is a suitable option for pain relief in clients with a history of peptic ulcers because it is less likely to cause irritation to the stomach lining compared to nonsteroidal anti-inflammatory drugs (NSAIDs).
Choice C reason
Aspirin is not appropriate: Aspirin is an NSAID with anti-inflammatory, analgesic, and antipyretic properties. Like other NSAIDs, it can increase the risk of stomach irritation and should be avoided in clients with a history of peptic ulcers.
Choice D reason:
Ibuprofen is not the right option: Ibuprofen is another NSAID commonly used for pain relief and reducing inflammation and fever. Like other NSAIDs, it can irritate the stomach lining and is not recommended for clients with a history of peptic ulcers.
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