and CORRECT Answers
While assessing a newborn infant in the nursery, you observe bounding 3+ radial pulses and faint
1+ pedal pulses. You also notice that the feet are cold and pale, while the hands are warm and
pink. Which cardiac defect do you suspect this infant has?
A. Tetralogy of Fallot (TOF)
B. Hypoplastic left heart syndrome
C. Coarctation of the aorta (COA)
D. Transposition of the great arteries - CORRECT ANSWER -C
Coarctation of the aorta is a narrowing of the aorta near the ductus arteriosus. Because of this
narrowing, there is increased blood flow to the upper extremities and decreased blood flow to the
lower extremities. That causes the symptoms described in the question: bounding upper pulses,
faint lower pulses, and overall better perfusion to the upper extremities.
What happens during the Tetralogy of Fallot? - CORRECT ANSWER - four defects are
combined - an overriding aorta, pulmonary stenosis, hypertrophy of the right ventricle, and a
VSD. At birth, the nurse would appreciate a murmur and mild to severe cyanosis, depending on
the case.
What happens during hypoplastic left heart syndrome? - CORRECT ANSWER - In
hypoplastic left heart syndrome, the left side of the heart is underdevelopment. The nurse would
note cyanosis and murmur at birth
What happens during the transposition of the great arteries? - CORRECT ANSWER - In
the transposition of the great arteries, the pulmonary artery leaves the left ventricle, and the aorta
,leaves the right ventricle. These infants are severely cyanotic at birth and need surgery early in
life,
Your client has a stat order for a cooling or hypothermia blanket. After you call the appropriate
department, the cooling blanket is delivered to your nursing care unit. What is the first thing you
should do concerning this stat order?
A. Inspect and run the equipment prior to use.
B. Immediately use the cooling blanket for the client because it is a stat order.
C. Ask the engineering department to perform preventive maintenance on it.
D. Inspect the blanket for any frayed cords before to protect against fire. - CORRECT
ANSWER -A
You must thoroughly inspect and run the equipment before use to ensure that it is appropriately
functioning BEFORE it is used. This inspection should include an overall assessment for frayed
electrical cords and documented evidence that the piece of equipment has had the mandated
preventive maintenance and safety inspections according to the facility's policies and procedure.
The oncoming nurse learns that her new patient is suffering from Syndrome of Inappropriate
Antidiuretic Hormone (SIADH) secretion. Which of the following nursing actions is the most
important?
A. Assess the patient's mental status
B. Provide oral hygiene
C. Keep accurate intake and output measurements
, D. Reduce stress and discomfort - CORRECT ANSWER -A
When caring for a patient with SIADH, the nurse should carefully monitor for changes in mental
status and level of consciousness. SIADH causes excess free water retention and hyponatremia,
which may lead to confusion and behavioral changes. These alterations in the mental state may
also lead to seizures. Patients with SIADH may also experience cardiac dysrhythmias.
The nurse is caring for a 10-year-old child on the pediatric unit. The nurse, when caring for this
age group, should be aware that:
A. The child will do something for another person if that person does something for the child.
B. The child now follows social standards for the good of all.
C. The child wants to follow the rules because of a need to be seen as "good."
D. The child finds satisfaction in following rules. - CORRECT ANSWER -C
According to Kohlberg's Stages of Moral Development, this pediatric client's behavior correlates
to the client being in Level 2 (Conventional Morality Level), Stage 3 (Good Boy-Good Girl)
stage of moral development. In this level/stage of moral development, the pediatric client is
focused on living up to social expectations and roles. There is an emphasis on conformity, being
"nice," and consideration of how choices influence relationships.
A home health nurse is providing educational information to a client with iron-deficiency
anemia. Which meal selection by the client would indicate to the nurse that the client understood
the educational information provided?
A. Roast beef, mashed potatoes, green beans, peach pie
B. Chicken salad, apple slices, french fries, ice cream