A nurse is preparing a care plan for an infant with a congenital heart disease who will undergo corrective surgery. What should be the priority nursing intervention postoperatively?

Monitor urine output closely.

Administer prescribed analgesics on schedule.

Encourage deep breathing and coughing exercises.

Elevate the head of the bed to a 30-degree angle.

Answer and Explanation

The Correct Answer is A

A) The answer is A. Monitoring urine output closely is essential postoperatively to assess kidney perfusion and fluid balance, as infants are at risk of fluid shifts after cardiac surgery.

B) Incorrect. While administering prescribed analgesics is important for postoperative pain management, it is not the priority intervention among the options provided.

C) Incorrect. Encouraging deep breathing and coughing exercises is important to prevent respiratory complications, but it is not the priority intervention immediately after cardiac surgery.

D) Incorrect. Elevating the head of the bed can help with respiratory effort, but it is not the priority intervention. Monitoring urine output and fluid balance is more critical in the early postoperative period.

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Correct Answer is A

Explanation

A) Correct answer. Weight gain and edema in the lower extremities can be signs of worsening heart failure in children with congenital heart defects. Fluid retention occurs due to the heart's inability to effectively pump blood, leading to fluid accumulation in the body.

B) This option is incorrect. While decreased heart rate and blood pressure within the normal range may be indicative of stable heart function, they are not specific indicators of worsening heart failure.

C) This option is incorrect. Improved appetite and increased physical activity level are positive indicators but do not specifically reflect the child's heart failure status.

D) This option is incorrect. Resolution of cyanosis and pink coloration of the lips and nail beds are positive signs of improved oxygenation and may indicate effective management of the heart defect but not the potential worsening of heart failure.

A. Encourage the client to participate in high-intensity aerobic exercises daily. B. Limit physical activities to mild exercises and avoid competitive sports. C. Advise against any physical activity for at least six months. D. Recommend participating in activities with prolonged standing to increase endurance.

Correct Answer is B

Explanation

A) Incorrect. Encouraging high-intensity aerobic exercises daily is not appropriate for a client with a congenital heart disease, as it can put excessive strain on the heart and may not be safe.

B) The answer is B. Limiting physical activities to mild exercises and avoiding competitive sports is recommended for clients with congenital heart diseases to prevent overexertion and potential complications.

C) Incorrect. Complete restriction of physical activity for six months is not necessary for most clients with congenital heart diseases. It is essential to promote safe and appropriate physical activities.

D) Incorrect. Activities with prolonged standing may increase venous return and potentially worsen certain congenital heart conditions. The focus should be on low to moderate intensity exercises.

QUESTIONS

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A nurse is preparing a care plan for an infant with a congenital heart disease who will undergo corrective surgery. What should be the priority nursing intervention postoperatively?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is B

Explanation

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