A nurse is caring for a school-age child who has heart failure. Which of the following interventions should the nurse implement?
Avoid giving the child live virus vaccines.
Weigh the child every other day.
Ensure that the child sleeps in an air-conditioned room.
Consolidate activities to promote the child's rest.
The Correct Answer is D
A. Avoid giving the child live virus vaccines. Children with heart failure can receive live vaccines unless they are immunocompromised (e.g., from immunosuppressive therapy).
B. Weigh the child every other day. Daily weights are necessary to monitor fluid retention, a key concern in heart failure.
C. Ensure that the child sleeps in an air-conditioned room. While a cool environment may be comfortable, this is not a priority intervention for heart failure management.
D. Consolidate activities to promote the child's rest. Children with heart failure experience fatigue easily due to reduced cardiac output. Grouping activities together minimizes energy expenditure and promotes adequate rest.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. "Perform a sterile dressing change 8 hr after the procedure." The initial dressing should be left in place for at least 24 hours, and any dressing changes should be performed per facility protocol.
B. "Keep the affected extremity straight for 4 hr." After a femoral venous cardiac catheterization, the child should keep the affected extremity straight for about 4 to 6 hours to prevent bleeding or hematoma formation at the insertion site.
C. "Assess the pulses above the catheterization site." The pulses below the site (distal pulses) should be assessed, not above. This is important to check for adequate circulation and potential complications such as clot formation or arterial obstruction.
D. "Maintain NPO status for 24 hr following the procedure." The child should typically resume oral intake as soon as they are fully awake and able to tolerate fluids, usually within a few hours post-procedure.
Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"B"}}
Explanation
Temperature: The temperature decreased from 38.8° C (101.8° F) to 37.6° C (99.7° F), which indicates a potential improvement in the infection response as the body temperature is coming down.
WBC count: The WBC count increased slightly from 14,000/mm³ to 15,000/mm³, which is still elevated compared to the normal range (5,000 to 10,000/mm³). This suggests that the body is still responding to infection and could indicate a worsening condition if the trend continues or remains elevated.
Weight-bearing ability on the affected leg: The improvement in weight-bearing ability suggests that the condition of the leg is improving. This indicates that the condition is improving as the pain or swelling may have decreased.
Wound assessment: The wound culture is still pending, and although there is no specific description provided, a pending culture and the general condition of the wound (which can be assessed for redness, warmth, or exudate) might still indicate a worsening condition if there is continued inflammation or signs of spreading cellulitis.
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