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.
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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Related Questions
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
Correct Answer is A
Explanation
A) The answer is A. Before administering digoxin, the nurse should check the infant's apical heart rate for a full minute. Digoxin is a medication used to improve cardiac contractility, and knowing the heart rate helps ensure the medication is given safely and at the correct dose.
B) Incorrect. While measuring blood pressure is essential in some cases, it is not the priority action before administering digoxin.
C) Incorrect. Assessing capillary refill time is an important part of the overall assessment, but it is not the priority action before giving digoxin.
D) Incorrect. While observing for respiratory distress is crucial, it is not the priority action in this specific scenario of preparing to administer digoxin. Checking the heart rate takes precedence.
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