Which intervention should be included in the plan of care for an infant with the nursing diagnosis of Excess Fluid Volume related to congestive heart failure?
Weigh the infant every day on the same scale at the same time.
Notify the physician when weight gain exceeds more than 20 g/day.
Put the infant in a car seat to minimize movement.
Administer digoxin as ordered by the physician.
The Correct Answer is D
Digoxin is a medication that helps improve the pumping function of the heart and reduces fluid retention in the lungs and other tissues. It is commonly used to treat congestive heart failure in infants.
Choice A is wrong because weighing the infant every day on the same scale at the same time is a way to monitor fluid balance, not an intervention to treat excess fluid volume.
Choice B is wrong because notifying the physician when weight gain exceeds more than 20 g/day is also a monitoring measure, not an intervention. Moreover, weight gain may not accurately reflect fluid volume status in some patients with heart failure due to poor nutrition and decreased appetite.
Choice C is wrong because putting the infant in a car seat to minimize movement may worsen the respiratory distress and increase the workload of the heart. The infant should be positioned in a semi-Fowler’s or Fowler’s position to facilitate breathing and reduce venous return.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
This test measures the amount of chloride in the sweat, which is abnormally high in people with cystic fibrosis (CF). CF is an inherited disorder that affects the cells that produce mucus, sweat, and digestive juices.
Choice A is wrong because bronchoscopy is a procedure that allows the doctor to examine the airways and lungs, but it is not essential for diagnosing CF.
Choice B is wrong because serum calcium is a blood test that measures the level of calcium in the blood, which is not related to CF.
Choice C is wrong because urine creatinine is a test that measures the amount of creatinine in the urine, which reflects the kidney function, but it is not relevant to CF.
Normal ranges for sweat chloride test are:
- Less than 40 millimoles per liter (mmol/L) for children and adults
- Less than 30 mmol/L for infants younger than 6 months
A sweat chloride level of more than 60 mmol/L is considered positive for CF.
Correct Answer is B
Explanation
Swimming is one of the best sports for people with hemophilia because it strengthens the muscles without putting stress on the joints. Swimming is also recommended by most sports physicians and hematologists for patients with hemophilia.
Choice A is wrong because soccer is a contact sport that can cause injuries and bleeding episodes in people with hemophilia. Soccer is not recommended by most sports physicians or hematologists for patients with hemophilia.
Choice C is wrong because basketball is also a contact sport that can lead to injuries and bleeding episodes in people with hemophilia. Basketball may be safe for young children, but the risk increases with the intensity of the game.
Choice D is wrong because football is a collision sport that can cause severe injuries and bleeding episodes in people with hemophilia. Football is not recommended by most sports physicians or hematologists for patients with hemophilia.
Normal ranges for hemophilia are:
- Mild hemophilia: 5% to 40% of normal clotting factor
- Moderate hemophilia: 1% to 5% of normal clotting factor
Severe hemophilia: less than 1% of normal clotting factor
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