Which nursing assessments are important when evaluating an infant with heart failure?
(Select All that Apply.)

Monitoring for tachycardia

Observing for diaphoresis during feeding

Monitoring for polyuria

Checking for hyperthermia

Assessing for hepatomegaly

Evaluating feeding difficulties

Answer and Explanation

Correct Answer : A,B,E,F

A. Monitoring for tachycardia – Correct. Tachycardia is an early sign of heart failure as the heart attempts to compensate for decreased cardiac output.

B. Observing for diaphoresis during feeding – Correct. Infants with heart failure often exhibit sweating while feeding due to increased effort and oxygen demand.

C. Monitoring for polyuria – Incorrect. Infants with heart failure are more likely to have oliguria due to poor perfusion, not excessive urination.

D. Checking for hyperthermia – Incorrect. Fever is not a primary sign of heart failure unless an infection is present.

E. Assessing for hepatomegaly – Correct. Hepatomegaly occurs due to systemic venous congestion, a hallmark of right-sided heart failure.

F. Evaluating feeding difficulties – Correct. Poor feeding and failure to thrive are common in infants with heart failure due to fatigue and respiratory distress.

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Correct Answer is D

Explanation

A. Treat bacterial infections – Incorrect. N-acetylcysteine is not an antibiotic.

B. Promote coughing and clear secretions – Incorrect. This describes its use in cystic fibrosis as a mucolytic, not in acetaminophen toxicity.

C. Reduce pain and fever – Incorrect. Acetaminophen, not N-acetylcysteine, is used for pain and fever.

D. Prevent liver damage – Correct. N-acetylcysteine replenishes glutathione stores, which helps detoxify acetaminophen metabolites that cause hepatotoxicity.

A. Amblyopia B. Hypotropia C. Otorrhea D. Exotropia

Correct Answer is A

Explanation

A. Amblyopia – Correct. Strabismus can lead to amblyopia (lazy eye) if left untreated.

B. Hypotropia – Incorrect. Hypotropia is a type of strabismus, not a complication.

C. Otorrhea – Incorrect. Otorrhea (ear drainage) is unrelated to strabismus.

D. Exotropia – Incorrect. Exotropia is another form of strabismus rather than a complication.

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Which nursing assessments are important when evaluating an infant with heart failure? (Select All that Apply.)

Nursing Test Bank

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Which nursing assessments are important when evaluating an infant with heart failure?
(Select All that Apply.)