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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Perform gastric lavage with activated charcoal. Activated charcoal is most effective if given within 1 hour of ingestion. Since the ingestion occurred 4 hours ago, activated charcoal would not be beneficial.
B. Begin hemodialysis within the next 24 hr. Hemodialysis is only used in severe cases of acetaminophen toxicity with liver failure, which is not indicated at this stage.
C. Prepare to give oral N-acetylcysteine. N-acetylcysteine (NAC) is the antidote for acetaminophen overdose and should be administered as soon as possible within 8 to 10 hours after ingestion to prevent liver damage.
D. Send the child home on increased fluid intake. Acetaminophen overdose can cause severe liver toxicity, so treatment in a medical setting is required, not just increased fluids at home.
Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"B"}
Explanation
Initiating airborne precautions. The child’s symptoms (fever, headache, nausea, lethargy, irritability, nuchal rigidity, and elevated WBC count) suggest bacterial or viral meningitis, which requires airborne precautions if tuberculosis or certain viral causes are suspected.
WBC. The child's WBC count is elevated (14,000 mm³), indicating a possible infection, which supports the need for precautions to prevent transmission.
Administering potassium chloride. The child's potassium level (3.8 mEq/L) is within the normal range (3.4-4.7 mEq/L), so potassium replacement is unnecessary.
Pain level. While pain management is important, it does not directly relate to the need for airborne precautions.
Administering acyclovir. Acyclovir is an antiviral used to treat herpes infections, but there is no indication in the scenario that the child has a viral infection requiring acyclovir.
Lymph node findings. While cervical lymphadenopathy can occur with infections, it does not necessarily indicate the need for acyclovir.
Increasing environmental stimuli. The child is already lethargic and irritable, so reducing stimuli (not increasing) would be more appropriate.
Potassium level. The potassium level is normal and does not indicate a need for intervention.
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