Which Intervention Should Be Included in the Plan of Care

question 3

Multiple Choice

Which intervention should be included in the plan of care for an infant with the nursing diagnosis of Excess Fluid Volume related to congestive heart failure?

• A)Weigh the infant every day on the same scale at the same time.
• B)Notify the physician when weight gain exceeds more than 20 g/day.
• C)Put the infant in a car seat to minimize movement.
• D)Administer digoxin (Lanoxin) as ordered by the physician.

---

Definitions:

Pinocytosis

Process by which vesicle formation brings macromolecules into the cell.

Exocytosis

Process in which an intracellular vesicle fuses with the plasma membrane so that the vesicle’s contents are released outside the cell.

Endocytosis

Process by which substances are moved into the cell from the environment; includes phagocytosis, pinocytosis, and receptor-mediated endocytosis.

Diffusion

The passive movement of particles from an area of high concentration to an area of low concentration.