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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?
- A. Weigh the infant every day on the same scale at the same time.
- B. Notify the physician when weight gain exceeds more than 20 g/day.
- C. Put the infant in a car seat to minimize movement.
- D. Administer digoxin as ordered by the physician.
Correct Answer: A
Rationale: Weighing the infant every day on the same scale at the same time is crucial in monitoring excess fluid volume in congestive heart failure. Sudden weight gain can indicate fluid retention, a common sign of worsening heart failure. Daily weight monitoring helps in early detection and timely intervention. Notifying the physician when weight gain exceeds more than 20 g/day might be too late for intervention. Daily weight monitoring is essential to detect trends and intervene promptly to manage excess fluid volume. Placing the infant in a car seat to minimize movement is not directly related to managing excess fluid volume in congestive heart failure. It is essential for safety during transportation but does not address the nursing diagnosis. Administering digoxin as ordered by the physician is a medical intervention for congestive heart failure. While important, the nursing diagnosis is related to excess fluid volume, and the focus should be on nursing interventions such as monitoring daily weights.
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A nurse is assisting with collecting data from a 10-month-old in the emergency department. Medical History: Guardians brought the infant to the emergency room after witnessing the infant's arms and legs shaking. The infant did not respond to the guardians' voices during that time. The episode lasted approximately 5 min and the infant was sleeping soundly afterwards. On the way to the emergency department, the infant had another episode of shaking of the extremities and drooling. The infant was asleep when they arrived for evaluation. The infant has no prior medical or surgical history. Born full-term at 40 weeks to a birth mother who had regular prenatal visits. Actions to Take: Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.
- A. Potential Condition
- B. Parameters to Monitor 1
- C. Parameters to Monitor 2
- D. Vitamin
- E. Blood pressure
Correct Answer: A
Rationale: The infant's symptoms suggest a possible seizure disorder. Seizures can cause symptoms such as shaking of the extremities and unresponsiveness. The fact that the infant was sleeping soundly after the episode and had another episode of shaking and drooling on the way to the emergency department further supports this. The nurse should monitor the infant's neurological status and vital signs, and administer anticonvulsant medication as ordered by the physician.
A nurse is caring for a child who has acute glomerulonephritis. Which of the following actions is the nurse's priority?
- A. Maintain a saline-lock.
- B. Place the child on a no-salt-added diet.
- C. Check the child's weight daily.
- D. Educate the parents about potential complications.
Correct Answer: C
Rationale: While maintaining a saline-lock can be important for administering medications or fluids, it is not the priority action. The nurse's priority should be to assess the child's condition and intervene to prevent complications. A no-salt-added diet may be recommended for some children with acute glomerulonephritis to help manage fluid balance and blood pressure. However, this is not the priority action. The nurse's priority should be to assess the child's condition and intervene to prevent complications. This is the correct answer. Checking the child's weight daily is a priority action because weight changes can indicate fluid retention or loss, which can affect kidney function. Regular weight checks can help guide treatment decisions and monitor the effectiveness of interventions. Educating the parents about potential complications is important, but it is not the priority action. The nurse's priority should be to assess the child's condition and intervene to prevent complications.
A nurse is caring for a client who is postoperative immediately following a tonsillectomy. Which of the following snacks should the nurse offer the client?
- A. Lime ice pop
- B. Cranberry juice
- C. Ice cream
- D. Apple juice
Correct Answer: A
Rationale: An orange ice pop is a good choice because it is cold and soothing for the throat, and it is also clear liquid which is usually recommended after tonsillectomy. Cranberry juice is not the best choice because it is acidic and can cause discomfort to the surgical site. Ice cream is not recommended immediately after surgery because dairy products can increase mucus production which can lead to coughing and discomfort. Apple juice is not the best choice because it is acidic and can cause discomfort to the surgical site.
What symptoms should a nurse expect in a 6-week-old infant admitted for evaluation of suspected pyloric stenosis?
- A. Projectile vomiting.
- B. Effortless regurgitation.
- C. Metabolic acidosis.
- D. Distended abdomen.
Correct Answer: A
Rationale: Projectile vomiting is a common symptom in infants with pyloric stenosis. This is due to the narrowing of the pylorus, the muscular valve at the bottom of the stomach, which prevents breast milk or formula from passing through to the small intestine. Effortless regurgitation is not typically associated with pyloric stenosis. The hallmark symptom of pyloric stenosis is projectile vomiting. Metabolic acidosis is not a typical symptom of pyloric stenosis. The hallmark symptom of pyloric stenosis is projectile vomiting. While a distended abdomen can occur in some cases of pyloric stenosis, it is not the most common symptom. The hallmark symptom of pyloric stenosis is projectile vomiting.
Upon finding a school-age child having a seizure, what should be the nurse's first action after lowering the client to the floor?
- A. Turn the client to a lateral position.
- B. Administer an anticonvulsant medication.
- C. Apply oxygen by nasal cannula.
- D. Check the client's oxygen saturation.
Correct Answer: A
Rationale: The first action a nurse should take upon finding a school-age child having a seizure is to ease the person to the floor and turn the person gently onto one side. This will help the person breathe and can prevent injury. Administering an anticonvulsant medication is not the immediate first action a nurse should take upon finding a child having a seizure. The first priority is to ensure the child's safety by easing them to the floor and turning them onto their side. Applying oxygen by nasal cannula is not the immediate first action a nurse should take upon finding a child having a seizure. The first priority is to ensure the child's safety by easing them to the floor and turning them onto their side. Checking the client's oxygen saturation is not the immediate first action a nurse should take upon finding a child having a seizure. The first priority is to ensure the child's safety by easing them to the floor and turning them onto their side.