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A nurse is caring for a 6-week-old infant.

Exhibits
Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.

Answer and Explanation

The Correct Answer is []

Condition Most Likely Experiencing: C

Actions to Take: A, B

Parameters to Monitor: B, C

Rationale:

Condition Most Likely Experiencing

A. Pyloric stenosis causes projectile vomiting, dehydration, and hunger.

B. Cystic fibrosis causes chronic respiratory infections, steatorrhea, and failure to thrive.

C. The condition that the infant is most likely experiencing is congestive heart failure, which can cause poor weight gain, tachypnea, decreased appetite, and periorbital edema.

D. Respiratory syncytial virus bronchiolitis causes wheezing, coughing, and respiratory distress.

Actions to Take

A. Digoxin is a medication commonly prescribed to manage congestive heart failure in infants by improving cardiac contractility and reducing heart rate.

B. Elevating the head of the bed helps reduce venous return to the heart, thereby decreasing preload and relieving symptoms of congestion in congestive heart failure.

C. Contact precautions are not indicated for congestive heart failure, but for infections that are transmitted by direct or indirect contact.

D. Chest physiotherapy and postural drainage are not indicated for congestive heart failure, but for conditions that cause excessive mucus production and retention.

Parameters to Monitor

A. Number of steatorrhea stools is not relevant for congestive heart failure, but for cystic fibrosis or other malabsorption disorders.

B. Monitoring intake and output is crucial in assessing fluid balance, especially in congestive heart failure where fluid retention can lead to volume overload.

C. Monitoring respiratory status is essential in congestive heart failure to assess for signs of pulmonary congestion and respiratory distress, such as tachypnea, retractions, and crackles.

D. Presence of periorbital edema is not a parameter to monitor, but a sign of fluid overload.

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Correct Answer is ["A","C","D","E","G"]

Explanation

A. Continuous monitoring of oxygen saturation is crucial in a vaso-occlusive crisis to detect any signs of hypoxia early, which could exacerbate the crisis and lead to more severe complications. This is important for assessing respiratory status, especially in patients with sickle cell disease who may be at risk for acute chest syndrome.

B. Oral intake should not be restricted during a vaso-occlusive crisis as hydration is important for maintaining adequate blood flow and preventing dehydration.

C. Hydroxyurea is used to reduce the frequency of painful crises in patients with sickle cell disease. It works by increasing the production of fetal hemoglobin, which can help prevent sickle cell crises.

D. Meperidine (Demerol) is an opioid analgesic commonly used to manage severe pain associated with sickle cell crises.

E. Vaccination is important in preventing infections, which can trigger or worsen a vaso-occlusive crisis in individuals with sickle cell disease. Ensuring the pneumococcal vaccine is current helps protect the adolescent from potential infections.

F. Placing the client on strict bed rest can increase the risk of thrombosis and impair circulation.

G. Folic acid supplementation is often recommended for patients with sickle cell disease to support red blood cell production and prevent folate deficiency, which can worsen anemia.

H. Cold compresses are not recommended as they can cause vasoconstriction, worsening the pain and sickling in vaso-occlusive crises. Warm compresses are generally preferred.

A. A toddler who has an apical pulse of 100/min B. A toddler who has a potassium level of 4.0 mEq/L (3.4 to 4.7 mEq/L) C. A toddler who has vomited 2 times in the last hour D. A toddler who has a digoxin level of 1.2 ng/mL (0.8 to 2 ng/mL)

Correct Answer is C

Explanation

A. An apical pulse of 100/min is within the normal range for a toddler. Digoxin should be administered cautiously if the heart rate is too low (below 90-100/min for young children), but 100/min is not a concern.

B. A potassium level of 4.0 mEq/L is within the normal range for toddlers (3.4-4.7 mEq/L), so there is no indication to revise the plan of care.

C. Vomiting is a sign of digoxin toxicity, and it requires immediate attention. The nurse should reassess the digoxin dose and check for other signs of toxicity, such as nausea, bradycardia, and arrhythmias.

D. A digoxin level of 1.2 ng/mL is within the therapeutic range for a toddler (0.8-2 ng/mL), so there is no need to revise the plan of care based on this finding.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for an adolescent who is admitted with a vaso-occlusive crisis. Exhibits The nurse is planning care for the adolescent. Select the 5 interventions the nurse should include.

Correct Answer is ["A","C","D","E","G"]

Explanation

A nurse is caring for a group of toddlers receiving digoxin therapy. For which of the following toddlers should the nurse revise the plan of care?

Correct Answer is C

Explanation

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A nurse on a pediatric unit is caring for four children. The nurse should use droplet precautions for which of the following children?

A nurse is reviewing the admission prescriptions for a 6-year-old child who has cystic fibrosis. For which of the following prescriptions should the nurse contact the child's provider?

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