A nurse is caring for a 6-week-old infant.
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.
The Correct Answer is []
Condition Most Likely Experiencing
- Pyloric stenosis causes projectile vomiting, dehydration, and hunger.
- Cystic fibrosis causes chronic respiratory infections, steatorrhea, and failure to thrive.
- 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.
- Respiratory syncytial virus bronchiolitis causes wheezing, coughing, and respiratory distress.
Actions to Take
- Digoxin is a medication commonly prescribed to manage congestive heart failure in infants by improving cardiac contractility and reducing heart rate.
- 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.
- Contact precautions are not indicated for congestive heart failure, but for infections that are transmitted by direct or indirect contact.
- 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
- Number of steatorrhea stools is not relevant for congestive heart failure, but for cystic fibrosis or other malabsorption disorders.
- Monitoring intake and output is crucial in assessing fluid balance, especially in congestive heart failure where fluid retention can lead to volume overload.
- 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.
- Presence of periorbital edema is not a parameter to monitor, but a sign of fluid overload.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Discarding the first voided specimen is necessary to ensure accuracy in a 24-hour urine collection. This helps eliminate any urine that has been in the bladder prior to the start of the collection period.
B. Voiding every hour is not necessary for a 24-hour urine collection. The goal is to collect all urine produced over a 24-hour period, not voiding at set intervals.
C. Cleansing the perineum with a povidone-iodine solution prior to voiding is not typically necessary for a 24-hour urine collection unless specifically instructed by the healthcare provider.
D. Saving the final specimen in a separate container is not necessary for a 24-hour urine collection. All urine produced during the specified collection period should be saved in the same container.
Correct Answer is D
Explanation
A. Stevens-Johnson syndrome is a severe adverse reaction associated with certain medications but is not typically associated with morphine.
B. Hypertension is not a common adverse effect of morphine; hypotension may occur instead.
C. Prolonged wound healing is not typically associated with morphine use.
D. Bradypnea (slow breathing) is a potential adverse effect of opioid medications such as morphine.
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