A nurse is caring for a child who is postoperative following surgical correction of Tetralogy of Fallot. Which of the following findings should the nurse identify as an indication of heart failure?
Weight loss
Decreased respirations
Exercise intolerance
Bradycardia
The Correct Answer is C
Choice A reason: Weight loss is not typically an indication of heart failure. In fact, patients with heart failure may experience weight gain due to fluid retention.
Choice B reason: Decreased respirations are not a common sign of heart failure. Instead, heart failure can cause increased respiratory rate and effort due to fluid accumulation in the lungs.
Choice C reason: Exercise intolerance, or difficulty in engaging in physical activity, is a classic symptom of heart failure. It occurs due to the heart's inability to pump enough blood to meet the body's demands during exercise.
Choice D reason: Bradycardia, or a slower than normal heart rate, is not a direct indication of heart failure. While it can be associated with certain cardiac conditions, it is not a specific sign of heart failure.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Hemoglobin (Hgb) of 12 g/dL is within the normal range for school-age children and is not specifically indicative of nephrotic syndrome.
Choice B reason: A serum protein level of 4.2 g/dL is lower than the normal range, which is typically between 6 and 8 g/dL. This finding is consistent with nephrotic syndrome, as the condition is characterized by proteinuria and hypoalbuminemia, leading to low serum protein levels.
Choice C reason: A BUN (Blood Urea Nitrogen) level of 15 mg/dL is within the normal range for children and does not specifically indicate nephrotic syndrome. Nephrotic syndrome is characterized by protein loss, not necessarily changes in BUN levels.
Choice D reason: A serum sodium level of 144 mEq/L is within the normal range for children. While electrolyte imbalances can occur in nephrotic syndrome, this value does not specifically indicate the condition.
Correct Answer is B
Explanation
Choice A reason: Using a 20-gauge needle for injections in a 3-month-old infant is not appropriate as it is too large. A smaller gauge needle should be used to minimize pain and tissue trauma.
Choice B reason: Providing a pacifier coated with an oral sucrose solution prior to the injections is an evidence-based practice to reduce pain in infants. The sweet taste of sucrose has a soothing effect and can help to distract the infant from the discomfort of the injection.
Choice C reason: Injecting immunizations into the deltoid muscle is not recommended for a 3-month-old infant as their muscle mass is not yet fully developed. The anterolateral thigh is the preferred site for intramuscular injections in infants.
Choice D reason: Applying eutectic mixture of local anesthetics (EMLA) cream immediately before the injections can help to numb the skin and reduce pain. However, it needs to be applied at least one hour before the procedure to be effective.
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