Nokea
The nurse is caring for a 2 month-old infant with a congenital heart defect. Which of the following is a priority nursing action?
- A. Provide small feedings every 3 hours
- B. Maintain intravenous fluids
- C. Add strained cereal to the diet
- D. Change to reduced calorie formula
Correct Answer: A
Rationale: Infants with congenital heart defects are at increased risk for developing congestive heart failure. Infants with congestive heart failure have an increased metabolic rate and require additional calories to grow. At the same time, however, rest and conservation of energy for eating is important. Feedings should be smaller and every 3 hours rather than the usual 4 hour schedule.
You may also like to solve these questions
During a situation of pain management, which statement is a priority to consider for the ethical guidelines of the nurse?
- A. The client's self-report is the most important consideration
- B. Cultural sensitivity is fundamental to pain management
- C. Clients have the right to pain management
- D. Nurses should not prejudge a client's pain using their own values
Correct Answer: A
Rationale: The client's self-report is the most important consideration. Pain is a complex phenomenon that is perceived differently by each individual. Pain is whatever the client says it is. The other statements are correct but not the most important considerations.
A nurse has been assigned to provide care to a client with suicidal ideation who is receiving treatment in an outpatient setting. The nurse develops a care plan and reviews it with the nurse preceptor before meeting with the client. Which proposed nursing action in the care plan requires intervention by the nurse preceptor?
- A. Assist the client in identifying the warning signs of a crisis
- B. Have the client write a list of people to contact for help and distraction
- C. Help the client develop ways of coping with suicidal thoughts
- D. Persuade the client to sign a contract promising not to attempt suicide
Correct Answer: D
Rationale: No-suicide contracts are not evidence-based and may create pressure rather than support coping strategies.
The nurse is reinforcing discharge instructions to the parent of a child with Kawasaki disease. The nurse informs the parent that the presence of which symptom should be immediately reported to the health care provider?
- A. Fever
- B. Irritability
- C. Joint pain
- D. Skin peeling
Correct Answer: A
Rationale: Fever in Kawasaki disease may indicate persistent inflammation or complications, requiring immediate reporting.
The nurse auscultates the heart sounds of a 77-year-old client with chronic heart failure. Which heart sound should the nurse document?
- A. Pericardial friction rub
- B. S1, S2, no adventitious sounds
- C. S3 extra heart sound
- D. Systolic murmur
Correct Answer: C
Rationale: An S3 heart sound is commonly associated with heart failure due to fluid overload and ventricular dysfunction.
The nurse is reinforcing teaching for a client recently diagnosed with heart failure who is being discharged with a prescription for lisinopril. Which of the following information should the nurse include?
- A. Instruct the client to have blood specimens obtained monthly to monitor serum medication levels
- B. Review foods that high in potassium that the client should regularly include in the diet
- C. Tell the client to check the pulse for 1 minute and hold the medication if the heart rate is <60/min
- D. Tell the client to rise slowly and sit on the side of the bed for several minutes before standing up
Correct Answer: D
Rationale: Lisinopril can cause orthostatic hypotension, so slow position changes prevent dizziness and falls.