What nursing action is appropriate to take when an infant with a congenital heart defect has increased respiratory rate, is sweating, and is not feeding well?
Check the infant’s temperature
Alert the physician
Increase the oxygen rate
Withhold oral feeding
The Correct Answer is B
A. Checking temperature is important, but these signs are more concerning for cardiac decompensation rather than infection.
B. The child may be experiencing heart failure or respiratory distress. Alerting the physician is the appropriate action to assess for worsening condition.
C. Increasing the oxygen rate might be necessary, but the priority is alerting the physician first for further assessment.
D. Withholding oral feeding may be necessary, but the priority is physician notification to guide management.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. The correct management involves obtaining blood cultures to identify the causative organism, starting high-dose antibiotics for treatment, and assessing for cardiac decompensation as the condition progresses.
B. While CBC and CXR may be ordered, starting aspirin is not a first-line treatment for infective endocarditis.
C. Cyanosis and high-dose steroids are not immediate interventions for infective endocarditis.
D. The first priority is antibiotics and blood cultures, not starting oxygen right away unless the child is hypoxic.
Correct Answer is B
Explanation
A. It is important to acknowledge potential postoperative discomfort to set realistic expectations for recovery and reduce anxiety.
B. Allowing the child to hear the ECG monitor sounds helps familiarize them with the equipment and can reduce fear or anxiety.
C. Explaining that an endotracheal tube may be needed is more accurate than giving false reassurance, as it could be required during surgery.
D. Showing unfamiliar equipment to the child can help reduce fear by familiarizing them with what they may encounter.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.
