An infant is admitted to the pediatric unit with heart failure due to a congenital heart defect. What assessment finding would the nurse expect with this diagnosis?
Polyuria
Difficulty feeding
Bradycardia
Bradypnea
The Correct Answer is B
Rationale:
A. Polyuria is not commonly associated with heart failure in infants; they are more likely to have oliguria or reduced urine output.
B. Difficulty feeding is a common sign of heart failure in infants because the increased work of breathing and poor cardiac output make it hard for them to feed effectively.
C. Bradycardia is not typically associated with heart failure; tachycardia is more common as the heart tries to compensate for decreased cardiac output.
D. Bradypnea is uncommon in heart failure; tachypnea is a more likely symptom due to fluid overload and poor oxygenation.
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Correct Answer is D
Explanation
Rationale:
A. While explaining discharge instructions is important, it is not the immediate priority following cast application.
B. Educating the client to elevate the leg is important to reduce swelling, but it is not the first priority.
C. Administering pain relief is necessary, but assessing circulation, sensation, and movement is more critical to identify any early signs of complications.
D. Performing a neurovascular assessment is the priority action because it ensures that there is no compromise to blood flow, sensation, or movement in the affected limb, which could indicate complications such as compartment syndrome.
Correct Answer is B
Explanation
Rationale:
A. Insulin doses should not be reduced when sick, as illness often increases blood glucose levels.
B. Eating a snack before physical activity helps prevent hypoglycemia, demonstrating a good understanding of how to manage blood glucose levels during exercise.
C. Counting carbohydrates, not fat calories, is essential for managing blood glucose levels in diabetes.
D. Blood glucose levels are typically checked before meals and at other key times, rather than only after meals.