The practical nurse (PN) is planning care for a child with heart failure. Which intervention should the PN give the greatest priority?

Monitor therapeutic level of phenytoin.

Increase ﬂuid intake.

Cluster care to conserve the child's energy.

Restrict intake of foods high in sugar.

Answer and Explanation

The Correct Answer is C

For a child with heart failure, the greatest priority for the practical nurse (PN) is to conserve the child's energy. Clustered care activities and rest periods will help to conserve the child's energy and minimize the workload on the heart.

Monitoring therapeutic levels of phenytoin (A) is not relevant to the care of a child with heart failure. Increasing ﬂuid intake (B) is not a priority intervention for a child with heart failure, as excessive ﬂuid intake can worsen heart failure. Restricting intake of foods high in sugar (D) may be necessary for a child with heart failure, but it is not the greatest priority for the PN to address.

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Correct Answer is B

Explanation

The information that poses the greatest risk for developing postpartum endometritis in this situation is that the client experienced spontaneous rupture of membranes (SROM) for 36 hours prior to delivery. SROM for an extended period of time increases the risk of infection, including postpartum endometritis, which is an infection of the uterus. The practical nurse (PN) should recognize this risk factor and monitor the client closely for signs of infection. The other information listed may also be important to consider, but SROM for 36 hours poses the greatest risk for developing postpartum endometritis in this situation.

A. Review prior insulin prescriptions. B. Check blood pressure. C. Obtain point-of-care glucose. D. Assess urine for ketones.

Correct Answer is C

Explanation

The first action the PN should take is to obtain a point-of-care glucose test. This will provide immediate information about the patient's blood sugar level and help guide further interventions.

Option A, reviewing prior insulin prescriptions, is important but not the first priority.

Option B, checking blood pressure, is also important but not the most immediate concern.

Option D, assessing urine for ketones, can provide useful information about the presence of ketones in the urine, which can indicate diabetic ketoacidosis, but it is not the first action that should be taken.

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The practical nurse (PN) is planning care for a child with heart failure. Which intervention should the PN give the greatest priority?

Nursing Test Bank

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Correct Answer is B

Explanation

The practical nurse (PN) is caring for an adolescent with type 1 diabetes mellitus who presents with an HbA1c of 11% (97 mmol/mol), thirst, and blurred vision. Which action should the PN take first?

Correct Answer is C

Explanation

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