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 B
Explanation
Choice A rationale:
Contacting the client's parents for phone consent might breach the adolescent's confidentiality, especially if they are seeking STI testing. In many jurisdictions, adolescents have the right to confidential healthcare, including STI testing and treatment, without parental consent. Respecting the adolescent's autonomy and confidentiality is crucial in this situation.
Choice B rationale:
Obtaining written consent from the client, if they are of legal age (which is often 16 or older in many jurisdictions), is appropriate and respects the adolescent's autonomy and legal rights. Written consent ensures that the adolescent fully understands the tests being conducted and gives informed consent for the procedure.
Choice C rationale:
Requesting verbal consent from the social worker is not appropriate. Verbal consent can be ambiguous and may not provide sufficient legal documentation of informed consent, especially for sensitive procedures like STI testing.
Choice D rationale:
Postponing the testing until the client's parents are present might not be in the best interest of the adolescent, especially if they are seeking timely healthcare. Delays in testing and treatment could lead to complications or the spread of STIs. Respecting the adolescent's autonomy and providing appropriate, timely care is essential in this situation.
Correct Answer is A
Explanation
Choice A rationale:
Varicella (chickenpox) is highly contagious and spreads through the air via respiratory droplets. Initiating airborne precautions, such as wearing masks and isolating the patient in a negative pressure room, helps prevent the spread of the virus to other patients and healthcare workers.
Choice B rationale:
Providing a warm blanket is a comfort measure and does not address the contagious nature of varicella. While keeping the child comfortable is important, preventing the spread of the infection to others is a higher priority.
Choice C rationale:
Koplik spots are small, white spots with blue or red centers that can appear on the oral mucosa in individuals with measles. Varicella does not cause Koplik spots; this finding is specific to measles. Therefore, assessing for Koplik spots is not relevant in the context of varicella.
Choice D rationale:
Administering aspirin to a child with varicella is contraindicated due to the risk of Reye's syndrome, a potentially fatal condition characterized by acute brain and liver damage. Acetaminophen is the preferred antipyretic for managing fever in children with varicella.
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