NCLEX RN Practice Question # 962
NCLEX Examination.
Practice Question # 962.
nclex examination
Heart Failure (HF)
- HF is the inability of the heart to pump a sufficient amount of blood to meet the metabolic and oxygen needs of the body.
- In infants and children, inadequate cardiac output most commonly is caused by congenital heart defects (shunt, obstruction, or a combination of both) that produce an excessive volume or pressure load on the myocardium.
- In infants and children, a combination of left-sided and right-sided HF is usually present.
- The goals of treatment are to improve cardiac function, remove accumulated fluid and sodium, decrease cardiac demands, improve tissue oxygenation, and decrease oxygen consumption; depending on the cause, surgery may be required.
Assessment of early signs
- Tachycardia, especially during rest and slight exertion
- Tachypnea
- Profuse scalp diaphoresis, especially in infants
- Fatigue and irritability
- Sudden weight gain
- Respiratory distress
Nursing Interventions
- Monitor for early signs of HF.
- Monitor for respiratory distress (count respirations for 1 minute).
- Monitor apical pulse (count apical pulse for 1 minute), and monitor for dysrhythmias.
- Monitor temperature for hyperthermia and for other signs of infection, particularly respiratory infection.
- Monitor strict intake and output; weigh diapers as appropriate for most accurate output.
- Monitor daily weight to assess for fluid retention; a weight gain of 0.5 kg (1 lb) in 1 day is caused by the accumulation of fluid.