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.

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