NUR 311 Exam 3 Questions With Complete Solutions
4-year-old Thomas is 4 days post-op following first stage
surgery to repair his TOF. He has been extubated for 24 hours,
but still has his foley catheter and left chest tube in place. He is
taking a few PO fluids and continues on maintenance IV
therapy. On assessment you find the following: Thomas is
responsive to questions, HR 130, RR 32, BP 64/46, UOP
10ml/hr, O2 saturation 98%, chest-tube drainage <3ml. Today's
weight is 32 pounds (up 1/2lbs from yesterday). Which of the
following is the best course of action?
a. Continue to monitor vital signs and urine output every 2
hours.
b. Consider early heart failure and notify the practitioner.
c. Consider dehydration and increase IV fluids to 1 1/2 times
maintenance.
d. Consider chest-tube obstruction, check the connections
carefully and increase the suction slightly. Correct Answer B
- Signs of heart failure after surgery may include: tachycardia,
increased respirations, decreased urine output, narrowed pulse
pressure, chest tube stops draining, and shortness of breath.
A 14-year-old child is admitted with a diagnosis of "rule out
rheumatic fever." Based on the Jones criteria, the nurse assesses
for which of the following?
a. Polyarthritis and dental caries.
b. Fever, HA, and low blood cell count.
c. Chorea, muscle weakness, and decreased sed rate.
,d. Erythema, polyarthritis, and elevated ASO titer Correct
Answer D
- Diagnosed by either two major manifestations, or two minor
and one major symptom.
A 2-year-old child has a known cardiac defect is in CHF. Which
assessment findings best indicate to the nurse a toxic dose of
Digoxin?
a. Tachycardia and dysrhythmia
b. HA and diarrhea
c. Bradycardia, N/V
d. Tinnitus and nuchal rigidity Correct Answer C
- S/S include bradycardia, cardiac dysrhythmias, nausea,
vomiting, anorexia, HA, weakness, and fatigue.
A 3-year-old patient with a congenital atrial septal defect has
lived with the defect without significant problems until now.
Which of the following is an indication that the patient is
becoming hemodynamically symptomatic?
a. Bronchoconstriction
b. Wheezing
c. Extertional dyspnea
d. Intermittent claudication
e. BP 140/90 Correct Answer C
- Bronchoconstriction and wheezing are caused by smooth
muscle constriction, not a cardiac problem.
, - Intermitten claudication is cramping in the legs when blood is
not perfused adequately to the lower extremities during exercise.
This can happen without cardiac issues.
- In this defect, blood is being shunted from left to right, causing
pulmonary blood flow to increase. This can cause pulmonary
edema that interferes with gas exchange, especially when the
child is active.
A 6-week-old infant is admitted from the clinic in CHF
following diagnosis of a ventricular septal defect (VSD). On
admission his HR is 170, RR 84, BP 76/40, and O2 saturation
96%. He is very tired and irritable and has mild retractions but
no edema. He has been feeding poorly for several days. He is
started on Digoxin and Lasix. In planning fluid and nutrition for
the next 12 hours, you would expect which of the following
interventions to be ordered?
a. Push bottle feeding every 3 hours.
b. Make him NPO and run IV fluids at 1/2 maintenance.
c. Place an NG feeding tube and institute feedings to meet
maintenance fluid requirements.
d. Begin infant on high-calorie formula and bottle-feed every 4-
5 hours. Correct Answer C
- You would never feed someone by mouth if their RR is 84
because they are at risk for aspirating the food.
- It would be good to administer high-calorie formula, but
feedings every 4-5 hours is too long. CHF patients need frequent
meals.
- If the gut works, use it. So don't go straight to IV fluids instead
of into the stomach.
4-year-old Thomas is 4 days post-op following first stage
surgery to repair his TOF. He has been extubated for 24 hours,
but still has his foley catheter and left chest tube in place. He is
taking a few PO fluids and continues on maintenance IV
therapy. On assessment you find the following: Thomas is
responsive to questions, HR 130, RR 32, BP 64/46, UOP
10ml/hr, O2 saturation 98%, chest-tube drainage <3ml. Today's
weight is 32 pounds (up 1/2lbs from yesterday). Which of the
following is the best course of action?
a. Continue to monitor vital signs and urine output every 2
hours.
b. Consider early heart failure and notify the practitioner.
c. Consider dehydration and increase IV fluids to 1 1/2 times
maintenance.
d. Consider chest-tube obstruction, check the connections
carefully and increase the suction slightly. Correct Answer B
- Signs of heart failure after surgery may include: tachycardia,
increased respirations, decreased urine output, narrowed pulse
pressure, chest tube stops draining, and shortness of breath.
A 14-year-old child is admitted with a diagnosis of "rule out
rheumatic fever." Based on the Jones criteria, the nurse assesses
for which of the following?
a. Polyarthritis and dental caries.
b. Fever, HA, and low blood cell count.
c. Chorea, muscle weakness, and decreased sed rate.
,d. Erythema, polyarthritis, and elevated ASO titer Correct
Answer D
- Diagnosed by either two major manifestations, or two minor
and one major symptom.
A 2-year-old child has a known cardiac defect is in CHF. Which
assessment findings best indicate to the nurse a toxic dose of
Digoxin?
a. Tachycardia and dysrhythmia
b. HA and diarrhea
c. Bradycardia, N/V
d. Tinnitus and nuchal rigidity Correct Answer C
- S/S include bradycardia, cardiac dysrhythmias, nausea,
vomiting, anorexia, HA, weakness, and fatigue.
A 3-year-old patient with a congenital atrial septal defect has
lived with the defect without significant problems until now.
Which of the following is an indication that the patient is
becoming hemodynamically symptomatic?
a. Bronchoconstriction
b. Wheezing
c. Extertional dyspnea
d. Intermittent claudication
e. BP 140/90 Correct Answer C
- Bronchoconstriction and wheezing are caused by smooth
muscle constriction, not a cardiac problem.
, - Intermitten claudication is cramping in the legs when blood is
not perfused adequately to the lower extremities during exercise.
This can happen without cardiac issues.
- In this defect, blood is being shunted from left to right, causing
pulmonary blood flow to increase. This can cause pulmonary
edema that interferes with gas exchange, especially when the
child is active.
A 6-week-old infant is admitted from the clinic in CHF
following diagnosis of a ventricular septal defect (VSD). On
admission his HR is 170, RR 84, BP 76/40, and O2 saturation
96%. He is very tired and irritable and has mild retractions but
no edema. He has been feeding poorly for several days. He is
started on Digoxin and Lasix. In planning fluid and nutrition for
the next 12 hours, you would expect which of the following
interventions to be ordered?
a. Push bottle feeding every 3 hours.
b. Make him NPO and run IV fluids at 1/2 maintenance.
c. Place an NG feeding tube and institute feedings to meet
maintenance fluid requirements.
d. Begin infant on high-calorie formula and bottle-feed every 4-
5 hours. Correct Answer C
- You would never feed someone by mouth if their RR is 84
because they are at risk for aspirating the food.
- It would be good to administer high-calorie formula, but
feedings every 4-5 hours is too long. CHF patients need frequent
meals.
- If the gut works, use it. So don't go straight to IV fluids instead
of into the stomach.
