Page 1073 - Saunders Comprehensive Review For NCLEX-RN

8. Weigh child daily.
9. Provide passive range-of-motion exercises to facilitate
joint movement.

10. Administer acetylsalicylic acid as prescribed

for its antipyretic and antiplatelet effects (additional
anticoagulation may be necessary if aneurysms are
present).

11. Administer immunoglobulin intravenously as

prescribed to reduce the duration of the fever and the
incidence of coronary artery lesions and aneurysms;
intravenous immunoglobulin is a blood product, so
blood precautions when administering it are
warranted.

12. Parent education (Box 36-7)

Box 36-1

Signs and Symptoms of Heart Failure

Left-Sided Failure

▪ Crackles and wheezes
▪ Cough
▪ Dyspnea
▪ Grunting (infants)
▪ Head bobbing (infants)
▪ Nasal flaring
▪ Orthopnea
▪ Periods of cyanosis

▪ Retractions
▪ Tachypnea

Right-Sided Failure

▪ Ascites
▪ Hepatosplenomegaly
▪ Jugular vein distention
▪ Oliguria
▪ Peripheral edema, especially dependent edema, and periorbital edema
▪ Weight gain

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