Nokea
An appropriate nursing action to include in the care of an infant with congenital heart disease who has been admitted with heart failure is:
- A. Positioning flat on the back
- B. Encouraging nutritional fluids
- C. Offering small frequent feedings
- D. Measuring the head circumference
Correct Answer: C
Rationale: Infants with congenital heart disease who have been admitted with heart failure may have difficulty feeding due to increased work of breathing and poor energy reserves. Offering small, frequent feedings can help prevent fatigue and provide adequate nutrition to support the infant's growth and recovery. It also helps to prevent overloading the heart with a large volume of fluids at once. This approach allows the infant to receive enough calories while reducing the risk of aspiration and conserving energy for feeding and breathing. Positioning the infant flat on the back may worsen respiratory distress, encouraging nutritional fluids alone may not address the feeding challenges faced by the infant, and measuring the head circumference is important for growth monitoring but may not be the priority when managing heart failure in this case.
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The nurse is assigned to a client with polymyositis. Which expected outcome in the plan of care relates to a potential problem associated with polymyositis?
- A. "Client will lose 2lb per week on a calorie-restricted diet."
- B. "Client will exhibit no signs or symptoms of aspiration."
- C. "Client will exhibit bowel and bladder continence."
- D. "Client will exhibit alertness and orientation to person, place, and time."
Correct Answer: B
Rationale: Polymyositis is a condition that involves inflammation of the muscles, including the muscles involved in swallowing (dysphagia) and breathing. This can lead to a higher risk of aspiration, where food or fluids go into the airway instead of the esophagus. Therefore, monitoring for signs and symptoms of aspiration and ensuring the client exhibits no signs of aspiration are crucial in the care of a client with polymyositis. The other options are not directly related to the potential problems associated with polymyositis and are more general aspects of nursing care.
Which of the ff. does the nurse understand usually precedes rheumatic fever?
- A. A viral infection
- B. A beta-hemolytic streptococcal
- C. A fungal infection infection c.A staphylococcal infection
Correct Answer: B
Rationale: Rheumatic fever is an inflammatory disease that can develop as a complication of untreated or inadequately treated infections caused by group A beta-hemolytic streptococci. These bacterial infections are usually in the form of strep throat or scarlet fever. Rheumatic fever typically occurs 2-4 weeks after a streptococcal infection. The body's immune response to the streptococcal infection can lead to an autoimmune reaction, resulting in rheumatic fever. It is important to promptly diagnose and treat streptococcal infections to prevent the development of rheumatic fever.
Which action by the nurse is appropriate?
- A. Observe the patient for abnormal bleeding.
- B. Notify the physician and expect an order to increase the warfarin dose.
- C. Advise the patient to double today's dose of warfarin.
- D. Administer Vit. K per protocol.
Correct Answer: A
Rationale: The appropriate action by the nurse is to observe the patient for abnormal bleeding. Warfarin is an anticoagulant medication, and one of its serious side effects is excessive bleeding. It is important for the nurse to monitor the patient closely for signs of abnormal bleeding, such as easy bruising, blood in urine or stool, or prolonged bleeding from cuts or wounds. This observation allows for early detection and intervention if any abnormal bleeding occurs. Notifications to the healthcare provider should also be made if abnormal bleeding is suspected. It is crucial not to make any changes to the warfarin dose or administer Vitamin K without a physician's order, as these actions can have serious consequences.
Which of the ff. nursing interventions will help prevent complications in the patient with Bell's Palsy?
- A. Megavitamin therapy
- B. Application of ice to the affected area
- C. Elastic bandages
- D. Lubricating eye drops
Correct Answer: D
Rationale: Bell's Palsy is a condition that affects the facial nerve, leading to weakness or paralysis of the facial muscles. One common complication of Bell's Palsy is the inability to fully close the affected eye, which can result in corneal exposure and dryness. Lubricating eye drops help prevent dryness and protect the cornea from damage due to inadequate eye closure. Using lubricating eye drops regularly can help maintain the eye's moisture and prevent potential complications such as corneal abrasions and infections, which are common in patients with Bell's Palsy. Megavitamin therapy, application of ice, and elastic bandages are not typically indicated for preventing complications in patients with Bell's Palsy.
Which of the ff. nursing interventions would have the highest priority in the plan of care for the postoperative eye patient?
- A. Do not leave the patient unattended at any time.
- B. Teach the patient not to bend over.
- C. Report sudden onset of acute pain.
- D. Apply sandbags to either side of the head.
Correct Answer: C
Rationale: In the postoperative period for an eye patient, sudden onset of acute pain can be indicative of a complication or an issue that needs immediate attention. Promptly reporting and addressing the pain is essential to prevent any further complications, such as infection, corneal abrasion, or increased intraocular pressure. This intervention takes priority over the other options listed as it involves the patient's immediate safety and well-being. It is crucial to follow postoperative protocols and report any unexpected or severe symptoms to ensure appropriate treatment and prevent any potential harm to the patient's eyesight.