A nurse is caring for a pediatric patient with congestive heart failure (CHF). What major goal should the nurse include in the care of this patient?

Prevent contractures of his hips and knees.

Minimize his cardiac output.

Minimize his energy expenditure.

Prevent vomiting.

Answer and Explanation

The Correct Answer is C

Choice A rationale:

Preventing contractures of the hips and knees is not directly related to the care of a pediatric patient with congestive heart failure (CHF). CHF primarily involves impaired cardiac function and fluid retention, not joint contractures.

Choice B rationale:

Minimizing cardiac output would be counterproductive in the care of a patient with CHF. The goal is to optimize cardiac output to meet the body's demands while managing the symptoms of CHF.

Choice C rationale:

Minimizing energy expenditure is a major goal in the care of a pediatric patient with CHF. CHF places an extra workload on the heart, and conserving energy helps prevent additional strain on the heart, allowing it to function more efficiently.

Choice D rationale:

Preventing vomiting is not a specific goal related to the care of a pediatric patient with CHF. Vomiting might be a symptom of CHF, but the primary focus is on managing cardiac function and fluid balance.

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Correct Answer is C

Explanation

Reviewing the patient's complete blood count.

Choice A rationale:

Measuring height is not a priority when administering zidovudine.

Choice B rationale:

Monitoring weight gain is important but not the first priority.

Choice C rationale:

Reviewing the complete blood count is crucial before administering zidovudine, as this medication can cause bone marrow suppression. Checking for changes in white blood cell counts, hemoglobin, and platelet levels is essential to ensure the patient can tolerate the medication without severe adverse effects.

Choice D rationale:

Reviewing the patient's chemistry profile is relevant, but assessing blood counts is more critical due to zidovudine's potential impact on bone marrow function.

A. Numbness and tingling feeling in her legs. B. Fever of 100.4°F (38°C). C. Pain at the incision site. D. Sleeping with occasional snoring.

Correct Answer is A

Explanation

Choice A rationale:

Collaborating with the team to begin peritoneal dialysis is the priority nursing intervention for a 9-year-old child with assessment findings of low urine output, high creatinine, and elevated blood urea nitrogen. These indicators suggest acute kidney injury, and initiating peritoneal dialysis is crucial to remove waste products and excess fluids.

Choice B rationale:

Strictly monitoring intake and output is important, but the child's current lab values and condition indicate the need for more immediate intervention through dialysis.

Choice C rationale:

Ensuring a low-sodium, low-phosphorus, and low-protein diet is important for renal health, but it's not the priority over addressing the acute kidney injury.

Choice D rationale:

Monitoring blood pressure is relevant but does not address the acute kidney injury that requires immediate attention. Assessment Findings for Adolescent Client:

Choice A rationale:

Numbness and tingling feeling in her legs require immediate action. These symptoms could indicate nerve compression or compromised blood flow due to the rod placement and need prompt assessment to prevent complications.

Choice B rationale:

A fever of 100.4°F (38°C) after surgery is common and can be managed with appropriate interventions, but it's not the most urgent concern in this case.

Choice C rationale:

Pain at the incision site is expected after surgery and should be managed appropriately, but it's not an immediate priority over potential neurovascular issues.

Choice D rationale:

Sleeping with occasional snoring might be related to anesthesia or positioning but doesn't require immediate action compared to the potential complications indicated by numbness and tingling.

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A nurse is caring for a pediatric patient with congestive heart failure (CHF). What major goal should the nurse include in the care of this patient?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is A

Explanation

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