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. Allowing the child to sit on the parent's lap can provide comfort and support during the procedure.
B. While the electrocardiogram (ECG) machine may have alarms, they are not typically related to abnormal heart rhythms during the procedure.
C. ECG leads are typically placed on the chest, not the back.
D. The duration of an ECG is relatively short, usually only a few minutes, so stating that it will take at least 30 minutes may cause unnecessary concern for the parent.
Correct Answer is A
Explanation
Rationale:
A. This is the priority action to confirm the correct placement of the NG tube in the stomach before administering the enteral feeding.
B. This should only be done after confirming proper tube placement.
C. Flushing the tube is necessary, but it should occur after confirming placement.
D. This should occur after confirming proper tube placement.
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