A nurse is assessing an infant. Which of the following should the nurse recognize as clinical
manifestations
of heart failure? (Select all that apply.)
A. Bradycardia
B. Cool extremities
C. Peripheral edema
D. Increased urinary output
E. Nasal flaring - Answers A. INCORRECT: A client who has heart failure will exhibit tachycardia as the
heart attempts to meet
the body's demands.
B. CORRECT: A client who has heart failure will exhibit cool extremities as the heart is unable to
adequately circulate oxygenated blood.
C. CORRECT: A client who has heart failure will exhibit peripheral edema as the heart is unable to
adequately circulate blood through the body and back to the heart.
D. INCORRECT: With heart failure, the heart is unable to keep up with the body's demands. A
decrease in urinary output is a clinical manifestation of heart failure.
E. CORRECT: A client who has heart failure will exhibit nasal flaring due to inadequate oxygenation
of blood
A nurse is caring for a 2-year-old child who is cyanotic and is in the hospital for a cardiac catheterization
to repair cardiac defects. The child will be transferred to the pediatric ICU following the procedure.
Which
of the following is an appropriate nursing action when providing care to this child?
A. Place on NPO status for 12 hr prior to the procedure.
B. Check for iodine or shellfish allergies prior to the procedure.
C. Elevate the affected extremity following the procedure.
, D. Limit fluid intake following the procedure - Answers A. INCORRECT: The child should remain NPO 4 to
6 hr prior to the procedure.
B. CORRECT: Iodine-based dyes may be used in this procedure, so the child is assessed for allergies to
iodine or shellfish which could lead to anaphylaxis.
C. INCORRECT: The affected extremity should be maintained in a straight position following the
procedure.
D. INCORRECT: Fluids should be encouraged after the procedure to maintain adequate urine output
and promote excretion of the dye.
The Foley Family is caring for their youngest child, Justin, who is suffering from tetralogy of Fallot. Which
of the following are defects associated with this congenital heart condition?
A. Aorta exits from the right ventricle, pulmonary artery exits from the left ventricle, and two
noncommunicating circulations
B. Ventricular septal defect, overriding aorta, pulmonic stenosis (PS), and right ventricular hypertrophy
C. Coarctation of aorta, aortic valve stenosis, mitral valve stenosis, and patent ductus arteriosus
D. Tricuspid valve atresia, atrial septal defect, ventricular septal defect, and hypoplastic right ventricle -
Answers Answer: B
B: The defects associated with tetralogy of Fallot include ventricular septal defect, overriding aorta,
pulmonic stenosis (PS), and right ventricular hypertrophy.
A: The aorta exiting from the right ventricle with no communication between the systemic and pulmonic
circulation describes the defects associated with transposition of the great vessels.
C: Coarctation of aorta and aortic and mitral valve stenosis are defects associated with tricuspid atresia.
Severe coarctation of aorta, severe aortic valvular stenosis or atresia, and severe mitral valve stenosis or
atresia are defects associated with hypoplastic left heart syndrome.
D: Also, the left ventricle, aortic valve, mitral valve, and ascending aorta usually are small or hypoplastic.
When creating a teaching program for the parents of Jessica who is diagnosed with pulmonic stenosis
(PS), Nurse Alex would keep in mind that this disorder involves which of the following?