A nurse is planning care for an 8-month-old infant who has heart failure.
Which of the following actions should the nurse include in the plan of care?
Administer cool, humidified oxygen via nasal cannula.
Provide less frequent, higher volume feedings.
Place the infant in a prone position.
Repeat a digoxin dosage if the infant vomits within 1 hr of administration.
The Correct Answer is A
Choice A rationale:
Administer cool, humidified oxygen via nasal cannula. Infants with heart failure often experience respiratory distress due to inadequate oxygenation. Administering cool, humidified oxygen via nasal cannula helps improve oxygen saturation and alleviate respiratory distress. Humidified oxygen prevents the mucous membranes from drying out, making breathing easier for the infant. Cool oxygen is preferred to reduce the work of breathing and to soothe irritated airways, improving the overall comfort of the infant.
Choice B rationale:
Provide less frequent, higher volume feedings. Infants with heart failure may have difficulty feeding due to fatigue and increased respiratory effort. Providing less frequent, higher volume feedings ensures that the infant receives adequate nutrition without becoming overly fatigued during feeding sessions. It allows the infant to obtain the necessary nutrients without putting excessive stress on their weakened cardiovascular system.
Choice C rationale:
Place the infant in a prone position. Placing the infant in a prone position is not recommended in the care of a child with heart failure. Placing the infant in an upright or semi-upright position is more appropriate as it reduces the workload on the heart and improves respiratory function. Placing the infant flat on their back may cause increased pressure on the diaphragm and worsen respiratory distress.
Choice D rationale:
Repeat a digoxin dosage if the infant vomits within 1 hr of administration. Digoxin is a medication commonly prescribed for heart failure. However, if the infant vomits shortly after receiving a dose, repeating the dose is not advisable. Vomiting may indicate that the medication was not properly absorbed, and administering an additional dose could lead to an overdose. Instead, the nurse should consult the healthcare provider for further instructions and closely monitor the infant's condition.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Teaching the child about cast care is essential, but it is not the first priority. The immediate concern is addressing the child's comfort and preventing complications associated with the fractured right tibia. Teaching can come after addressing the acute needs.
Choice B rationale:
Petaling the edges of the cast might be necessary to prevent skin irritation, but it is not the first action to take. Elevating the child's leg is crucial to reduce swelling and promote blood circulation, which is the priority in this situation.
Choice C rationale:
Administering pain medication is important for the child's comfort, but it should not be the first action. Elevating the leg helps in reducing pain and swelling and promotes overall healing.
Choice D rationale:
Elevating the child's leg is the first action the nurse should take. Elevating the leg above heart level helps reduce swelling and improves blood circulation, which is crucial in the initial phase after applying the cast. This action can help prevent complications and promote the healing process. Once the leg is elevated, the nurse can then proceed with teaching the child about cast care and administering pain medication if needed.
Correct Answer is C
Explanation
The correct answer is Choice C. Hyporeflexia.
Choice A rationale:
Oliguria, or reduced urine output, can be associated with dehydration or renal impairment, but it is not directly related to hypokalemia (low potassium levels). Hypokalemia primarily affects the muscles and heart rather than urine output.
Choice B rationale:
Hypertension is typically associated with high blood pressure and can be seen in conditions like hyperaldosteronism or Cushing's syndrome. However, it is not a direct result of hypokalemia. Low potassium levels usually lead to other cardiovascular issues such as arrhythmias, but not hypertension.
Choice C rationale:
Hyporeflexia, or decreased reflexes, is a common sign of hypokalemia. Potassium is essential for proper nerve and muscle function. When potassium levels are low, nerve impulses are slowed, leading to diminished reflexes. This symptom aligns with the preschooler's potassium level of 3.2 mEq/L, which is below the normal range.
Choice D rationale:
Hyperactive bowel sounds are not typically associated with hypokalemia. In fact, low potassium levels can lead to a reduction in gastrointestinal motility, potentially causing constipation or decreased bowel sounds, rather than hyperactivity.
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