ACCURATE AND VERIFIED ANSWERS
Terms in this set (41)
The RN is monitoring an infant with 3. tachycardia
CHD closely for SSx of HF. The RN
should assess the infant for which RATIONALE:
early sign of HF? HF is the inability of the heart to pump a sufficient
amt of blood to meet the O2 and metabolic
1.Pallor needs of the body. The early SSx of HF include
2.Cough tachycardia, tachypnea, profuse scalp sweating,
3.Tachycardia fatigue & irritability, sudden weight gain, and resp
4.Slow and shallow breathing distress. A cough may occur in HF as a result of
mucosal swelling & irritation, but is not an early
sign. Pallor may be noted in an infant w/ HF, but is
not an early sign.
The nurse reviews the laboratory 4. anti-streptolysin O titer
results for a child with a suspected
diagnosis of rheumatic fever, RATIONALE:
knowing that which laboratory Rheumatic fever is an inflammatory autoimmune
study would assist in confirming the disease that affects the CT of the heart, joints,
diagnosis? skin (SQ tissues), BV, and CNS. A Dx of rheumatic
fever is confirmed by the presence of 2 major
1.Immunoglobulin manifestations or 1 major and 2 minor
2.Red blood cell count manifestations from the Jones criteria. In addition,
3.White blood cell count evidence of a recent strep infection is confirmed
4.Anti-streptolysin O titer by a + anti-streptolysin O titer, streptozyme assay,
or anti-DNase B assay.
,On assessment of a child 3. conjunctival hyperemia
admitted with a diagnosis of
acute-stage Kawasaki disease, the
RATIONALE:
nurse expects to note which clinical
Kawasaki disease, aka mucocutaneous lymph
manifestation of the acute stage
node syndrome, is an acute systemic
of the disease?
inflammatory illness. In the acute stage, the child
has a fever, conjunctival hyperemia, red throat,
1. Cracked lips
swollen hands, rash, and enlargement of the
2. Normal appearance
cervical lymph nodes. In the subacute stage,
3.Conjunctival hyperemia
cracking lips and fissures, desquamation of the
4.Desquamation of the skin
skin on the tips of the fingers and toes, joint pain,
cardiac manifestations, and thromobocytosis
occur. In the convalescent stage, the child
appears normal, but SSx of inflammation may be
present
The mother of a child being 4. "The child may return to school in 3 weeks but
discharged after heart surgery needs to go half-days for the 1st few days"
asks the nurse when the child
will be RATIONALE:
able to return to school. Which is After heart surgery, the child may be able to
the most appropriate response to return to school in 3 weeks but needs to go half-
the mother? days for the 1st few days. The mother also
should be told that the child cannot participate
1. "The child may return to school in
in PE for 2 months.
1 week."
2. "The child will not be able
to return to school during
this academic year."
3. "The child may return to school
in 1 week but needs to go half-
days for the first 2 weeks."
4. "The child may return to school
in 3 weeks but needs to go half-
days for the first few days."
, Prostaglandin E1 is prescribed for a 2. maintains adequate CO
child with transposition of the great
arteries. The mother of the child is
RATIONALE:
a registered nurse and asks the
A child with transposition of the great
nurse why the child needs the
arteries may receive prostaglandin E1
medication. What is the most
temporarily to
appropriate response to the
increased blood mixing if systemic and
mother about the action of the
pulmonary mixing is inadequate to maintain
medication?
adequate CO.
1. Prevents blue (tet) spells
2. Maintains adequate
cardiac output
3. Maintains an adequate
hormonal level
4. Maintains the position of the
great arteries
The nurse is assessing a 4. withhold the med and notify HCP
newborn with heart failure
before administering the
RATIONALE:
prescribed
The apical pulse rate for a newborn is 120-160
digoxin. In reviewing the laboratory
bpm. The therapeutic dig level is 0.5-0.8. Bc the
data, the nurse notes that the
apical rate is low and the dig blood level is
newborn has a digoxin blood
elevated, indicating toxicity, the RN would
level of 1.6 ng/mL (2.05 mmol/L)
withhold the med and notify the HCP
and an apical heart rate of 90
beats/min.
The mother also tells the nurse
that the newborn just vomited
her
formula. Which intervention
should the nurse take?
1. Retake the apical pulse.
2. Administer the medication.
3. Withhold the medication for
1 hour.
4. Withhold the medication
and notify the health care
provider.