Nursing care of the infant and child with congestive heart failure would include which of the following?
Organize activities to allow for uninterrupted sleep and frequent rest periods.
Force fluids appropriate to age to keep well hydrated.
Continuously monitor respirations during active periods.
Give larger feedings less often to conserve energy
The Correct Answer is A
A. Infants and children with congestive heart failure (CHF) have increased metabolic demands and often experience fatigue with activity. Organizing care to allow uninterrupted sleep and frequent rest periods helps conserve energy and promotes recovery.
B. Forcing fluids can be dangerous in CHF due to the risk of fluid overload, which can worsen symptoms like pulmonary edema.
C. While monitoring respiratory status is important, continuous monitoring during active periods is not a standard or necessary nursing intervention.
D. Giving larger feedings less often is not appropriate, as it can lead to fatigue and increased oxygen demand. Instead, smaller, more frequent feedings are recommended to conserve energy.
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Related Questions
Correct Answer is C
Explanation
A. Edema in the legs and feet is more commonly associated with right-sided heart failure, not specifically with patent ductus arteriosus (PDA).
B. While oxygenation may improve after closure, the primary issue in PDA is not poor oxygenation but inefficient circulation.
C. In PDA, oxygenated blood from the aorta flows back into the pulmonary artery, causing extra blood to return to the lungs. Surgical closure prevents this left-to-right shunt, thereby reducing pulmonary overcirculation and improving cardiac efficiency.
D. The problem with PDA is not loss of unoxygenated blood to the systemic circulation — it’s the recirculation of already oxygenated blood to the lungs.
Correct Answer is D
Explanation
A. A humidifier can help keep secretions moist and reduce discomfort, but it does not prevent aspiration and is not a priority in the immediate postoperative period.
B. Suctioning the nasopharynx should be done with caution after a tonsillectomy, as it can irritate the surgical site and cause bleeding; it is not a routine action to prevent aspiration.
C. Chest physiotherapy is not appropriate in the immediate postoperative period following a tonsillectomy and could increase the risk of bleeding.
D. After a tonsillectomy, the nurse should withhold oral fluids until the child is fully awake and has a demonstrated gag reflex, which helps ensure that the airway is protected and reduces the risk of aspiration.
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