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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 B

Explanation

A. Droplet precautions are not needed for impetigo; it is spread through direct contact with lesions or contaminated items.

B. Wearing gloves when assessing the toddler is important to prevent the spread of impetigo, which is highly contagious.

C. Negative airflow rooms are not required for impetigo.

D. Protective environments are for immunocompromised patients, which is not necessary for impetigo.

A. Reinforce the dressing. B. Obtain vital signs. C. Apply pressure just above the insertion site. D. Monitor the pulse distal to the insertion site.

Correct Answer is C

Explanation

A. Reinforcing the dressing is not sufficient to control bleeding. Pressure needs to be applied directly.

B. Vital signs are important to monitor, but stopping the bleeding is the priority action first.

C. Applying pressure just above the insertion site is the first action to control bleeding after a cardiac catheterization. Immediate pressure helps to stop the bleeding before further actions are taken.

D. Monitoring the pulse distal to the insertion site is important to assess circulation, but controlling the bleeding comes first.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a toddler who has impetigo. Which of the following actions by the nurse indicates an understanding of how impetigo is spread?

Correct Answer is B

Explanation

A nurse is assessing a child who is 2 hr postoperative following a cardiac catheterization and finds the dressing is saturated with blood. Which of the following actions should the nurse take first?

Correct Answer is C

Explanation

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