RN HESI PAEDIATRICS Exam 2
RN HESI PAEDIATRICS Exam 2 ( 48 Questions)
A 6-year-old with heart failure (HF) gained 2 pounds (0.9 kg) in the last 24 hours. Which intervention is most important for the nurse to implement?
reason:
Restrict intake of oral fluids: While fluid restriction may be necessary in managing heart failure, it's important to first assess the child's respiratory status and lung sounds to determine if there is fluid overload causing pulmonary congestion.
reason:
Assess bilateral lung sounds is the appropriate recommendation. In a child with heart failure, a sudden weight gain can indicate fluid retention, which may lead to worsening congestion and pulmonary edema. Assessing bilateral lung sounds is crucial to identify signs of fluid accumulation in the lungs. Abnormal lung sounds, such as crackles or wheezes, may indicate pulmonary congestion and require immediate attention.
reason:
Graphing the daily weight is important for monitoring trends, but when a sudden weight gain is observed, the immediate priority is to assess the child's condition, particularly their respiratory status.
reason:
Decrease Intravenous (IV) flow rate: Adjusting the IV flow rate may be necessary, but this should be done based on a comprehensive assessment that includes evaluating lung sounds and other clinical indicators. Simply decreasing the IV flow rate without assessing the child's lung sounds could potentially overlook a critical issue.