A nurse is caring for a school-age child who has heart failure. Which of the following interventions should the nurse implement?
Ensure that the child sleeps in an air-conditioned room.
Avoid giving the child live virus vaccines.
Weigh the child every other day.
Consolidate activities to promote the child's rest.
The Correct Answer is D
A. Ensure that the child sleeps in an air-conditioned room: While a cool and comfortable environment may reduce stress and promote rest, air conditioning alone does not address the management of heart failure. It is supportive but not a priority nursing intervention.
B. Avoid giving the child live virus vaccines: Live virus vaccines are typically avoided in immunocompromised clients or those on immunosuppressive therapy, not specifically for stable pediatric heart failure.
C. Weigh the child every other day: Children with heart failure are at risk for fluid retention, and daily weights provide the accurate and timely assessment of fluid status. Weighing every other day could delay the identification of fluid overload and compromise early intervention.
D. Consolidate activities to promote the child's rest: Children with heart failure often experience fatigue due to decreased cardiac output. Organizing care to allow longer rest periods helps reduce cardiac workload and conserves energy.
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Related Questions
Correct Answer is C
Explanation
A. Oxygen saturation: An oxygen saturation of 95% is within the normal range for a school-age child and acceptable for a client with cystic fibrosis, who may have mild baseline respiratory compromise.
B. WBC count: A WBC count of 9,600/mm³ is within the normal pediatric range (5,000–10,000/mm³). It does not suggest acute infection or bone marrow suppression, so it is not a reportable finding.
C. HbA1c: An HbA1c of 8.5% is significantly elevated above the normal range (4%–5.9%). This indicates poor glycemic control, suggesting cystic fibrosis–related diabetes, a common complication. This requires provider notification for further evaluation and management.
D. Heart rate: A heart rate of 98/min is within the normal range for school-age children (75–118/min). It does not indicate acute distress or cardiac complications, so it does not warrant immediate reporting.
Correct Answer is D
Explanation
A. Mild hematuria: In glomerulonephritis, hematuria is typically significant, often producing cola- or tea-colored urine. Mild hematuria alone would not reflect the degree of renal involvement usually seen with this condition.
B. Absent urine protein: Proteinuria is a common finding in glomerulonephritis due to increased permeability of the glomerular membrane. Absence of protein in the urine would not be expected.
C. Decreased blood potassium: Potassium levels usually remain normal or may increase if renal function becomes impaired. Hypokalemia is not a common laboratory finding in glomerulonephritis.
D. Hyponatremia: Children with glomerulonephritis often experience fluid retention and dilutional hyponatremia. The kidneys’ impaired ability to filter and excrete fluid contributes to low serum sodium levels.
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