A nurse is caring for a 6-week-old infant.
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 []
Correct Answers:
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. Elevating the head of the bed can help reduce the workload of the heart and improve breathing.
B. Digoxin can increase the contractility of the heart and decrease the heart rate.
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. Intake and output can indicate fluid balance and renal function.
C. Respiratory status can reflect cardiac function and oxygenation.
D. Presence of periorbital edema is not a parameter to monitor, but a sign of fluid overload.
Nursing Test Bank
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Related Questions
Correct Answer is A
Explanation
Rationale:
A. This is a positive reinforcement strategy that can motivate the child to take the medication and reduce the unpleasant taste.
B. Giving milk with the medication may not be suitable for all medications, and some medications may interact with dairy products.
C. Mixing the medication with the child's favorite food is not advised because it can alter the taste and texture of the food and make the child dislike it in the future.
D. Diluting the medication with water may not be appropriate for all medications, and it could alter the effectiveness or stability of the medication.
Correct Answer is A
Explanation
Rationale:
A. This is the priority action to confirm the correct placement of the NG tube in the stomach before administering the enteral feeding.
B. This should only be done after confirming proper tube placement.
C. Flushing the tube is necessary, but it should occur after confirming placement.
D. This should occur after confirming proper tube placement.
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