A nurse is caring for a school-age child who has heart failure. Which of the following findings should the nurse expect?Select all that apply.
Cyanosis
Weight loss
Bounding peripheral pulses
Dyspnea
Tachycardia
Correct Answer : A,D,E
Rationale:
A. Cyanosis can occur in children with heart failure due to inadequate oxygenation of tissues.
B. Weight gain or fluid retention is more common in children with heart failure.
C. Bounding pulses are more commonly associated with conditions such as hypertension or hyperthyroidism, rather than heart failure.
D. Dyspnea, or difficulty breathing, is a common symptom of heart failure due to fluid buildup in the lungs.
E. Tachycardia, or a rapid heart rate, can occur as a compensatory mechanism in response to decreased cardiac output in heart failure.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Rationale:
A. Maintaining droplet precautions while the child is coughing and sneezing is appropriate because pertussis is primarily transmitted via respiratory droplets. Droplet precautions include wearing a surgical mask when within 3 feet of the patient to prevent droplet transmission.
B. Applying a face mask after entering the child's room is not necessary if droplet precautions are already being followed during periods of coughing and sneezing.
C. Wearing gloves when assisting the child to the bathroom is not directly related to preventing the spread of pertussis, which is primarily transmitted via respiratory droplets.
D. Airborne precautions with an N95 respirator are not indicated for pertussis, as it is not transmitted via airborne particles.
Correct Answer is ["A","B","C","F","H"]
Explanation
Rationale:
A.Clients with sickle cell disease are at increased risk for infections, including those caused by pneumococcus. Ensuring vaccination status helps prevent future complications.
B. Folic acid supplementation may be part of the overall management of sickle cell disease, but it is not a priority intervention during a vaso-occlusive crisis.
C. Vaso-occlusive crises can lead to tissue hypoxia due to impaired blood flow.
Continuous monitoring of oxygen saturation helps in assessing tissue perfusion and detecting hypoxemia early.
D. Placing the client on strict bed rest can increase the risk of thrombosis and impair circulation.
E.Cold can cause vasoconstriction, worsening the pain and sickling process. Warm compresses are more appropriate for promoting comfort and improving circulation.
F. Meperidine (Demerol) is a potent opioid analgesic that can help alleviate severe pain associated with vaso-occlusive crises.
G. The nurse should not restrict oral intake, as hydration is important to prevent dehydration and further sickling.
H. Hydroxyurea is used to prevent vaso-occlusive crises in patients with sickle cell disease but is not typically administered during an acute crisis. This is a medication that reduces the frequency and severity of vaso-occlusive crises by increasing the production of fetal hemoglobin, which prevents sickling.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today