A nurse is assessing a toddler who has heart failure. Which of the following findings should the nurse expect?
Bradycardia
Weight loss
Orthopnea
Increased urine output
The Correct Answer is C
A. Bradycardia is not typically expected in toddlers with heart failure; instead, tachycardia (increased heart rate) is more common as the body compensates for decreased cardiac output.
B. Weight loss is generally not a typical finding in toddlers with heart failure; rather, they often experience weight gain due to fluid retention.
C. Orthopnea, or difficulty breathing when lying flat, is a common symptom of heart failure and would be expected in a toddler due to fluid overload affecting respiratory function.
D. Increased urine output is usually not expected in heart failure; rather, fluid retention often leads to decreased urine output as the kidneys respond to the body's fluid balance needs.
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Correct Answer is B
Explanation
A. Administering IV fluids may be necessary but is not the first priority in managing a suspected airway emergency.
B. Placing the child on droplet precautions is the first action to take to prevent the spread of infection and protect healthcare workers, given the suspected diagnosis of epiglottitis.
C. Initiating IV antibiotics is essential but should follow ensuring that appropriate precautions and assessments are in place.
D. While obtaining an x-ray can confirm the diagnosis, the child's safety and airway management must be prioritized first to avoid potential respiratory distress.
Correct Answer is C
Explanation
A. Monitoring lung function and oxygen saturation is important but not the primary purpose of chest physiotherapy.
B. Chest physiotherapy does not primarily focus on pain relief or reducing inflammation; instead, it targets mucus clearance.
C. Chest physiotherapy is primarily performed to enhance lung function by mobilizing and clearing thick mucus from the airways, which is critical in managing cystic fibrosis and preventing infections.
D. While medications can be administered via nebulization, chest physiotherapy itself is not used for direct medication delivery but rather for airway clearance.