NUR-114-NCLEX-Perfusion Practice with 100% correct answers

The nurse is monitoring an infant with congenital heart disease closely for signs of heart failure(HF). The nurse should assess the infant for which early sign of HF? A. Pallor B. Cough C. Tachycardia D. Slow and shallow breathing ANS: C HF is the inability of the heart to pump a sufficient amount of blood to meet the oxygen and metabolic needs of the body. The early signs of HF include tachycardia, tachypnea, diaphoresis, fatigue and irritability, sudden weight gain, and respiratory distress. A cough may occur in HF as a result of mucosal swelling and irritation, but is not an early sign. Pallor may be noted in an infant with HF but is not an early sign. The nurse provides home are instructions to the parents of a child with heart failure regarding the procedure for administration of digoxin. Which statement made by the parent indicates the need for further teaching? a. "I will not mix the medication with food" b. "If more than 1 dose is missed, I will call the pediatrician". c. "I will take my child's pulse before administering the medication." d. "If my child vomits after medication administration, I will repeat this dose." ANS: D Digoxin is a cardiac glycoside. The parents need to be instructed that if the child vomits after digoxin is administered, they are not to repeat the dose. Options 1,2,and 3 are accurate instructions regarding the administration of this medication. In addition, the parents should be instructed that if a dose is missed and is not identified until 4 hours later, the dose should not be administered. 00:00 01:36 The nurse is closely monitoring the intake and output of an infant with heart failure who is receiving diuretic therapy. The nurse should use which appropriate method to assess the urine output? a. weighing the diapers b. inserting a urinary catheter c. comparing intake with output d. measuring the amount of water added to formula ANS:A HF is the inability of the heart to pump a sufficient amount of blood to meet the oxygen and metabolic needs of the body. The most appropriate method for assessing urine output in an infant receiving diuretics' therapy is to weigh the diapers. Comparing intake with output would not provide an accurate measure of urine output. Measuring the amount of water added to formula is unrelated to the amount of output. Although urinary catheter drainage is most accurate in determining output, it is not the most appropriate method in an infant and places the infant at risk for infection. The nurse has provided home care instructions to the parents of a child who is being discharged after cardiac surgery. Which statement made by the parents indicate the need for further instruction? a. "a balance of rest and activity is important." b. "I can apply lotion or powder to the incision if it is itchy." c. "Activities in which my child could fall need to be avoided for 2 to 4 weeks." d. "Large crowds of people need to be avoided for at least 2 weeks after surgery." ANS:B The mother should be instructed that lotions and powders should not be applied to the incision site after cardiac surgery. Lotions and powders can irritate the surrounding skin which could lead to skin breakdown nd subsequent infection of the incision site. Option a, c, and d are accurate instructions regarding home care after cardiac surgery. A pediatrician has prescribed oxygen as needed for an infant with heart failure. In which situation should the nurse administer oxygen to the infant? a. During sleep b. when changing the infants diapers c. when he mother is holding the infant d. when drawing blood for electrolyte level testing ANS:D Crying exhausts the limited energy supply, increases the workload of the heart, and increases the oxygen demands. Oxygen administration may be prescribed for stressful periods, especially during bouts of crying or invasive procedures. Options A, B, and C are not likely to produce crying in the infant. A client with a history of type 2 diabetes is admitted to the hospital with chest pain. The client is scheduled for a cardiac catheterization. Which medication would need to be withheld for 24 hours before the procedure and for 48 hours after the procedure? a. Glipizide b. Metformin c. Repaglinide d. Regular insulin ANS: B Metformin needs to be withheld 24 hrs before and for 48 hours after cardiac catheterization because of the injection of contrast medium during the procedure. A client in sinus bradycardia, with a heart rate of 45 beats/minute, complains of dizziness and has a blood pressure of 82/60 mm Hg. Which prescription should the nurse anticipate will be prescribed? a. Defibrillate the client. b. Administer digoxin (Lanoxin). c. Continue to monitor the client. d. Prepare for transcutaneous pacing. ANS: D The nurse in a medical unit is caring for a client with HF. The client suddenly develops extreme dyspnea, tachycardia, and lung crackles. The nurse immediately asks another nurse to contact the primary health care provider and prepares to implement which priority interventions? Select all that apply. a. administering oxygen b. inserting a Foley catheter c. administering furosemide d. administering morphine sulfate intravenously transporting the client to the coronary care unit f. placing the client in a low-flower's side-lying position ANS:A, B, C,D extreme dyspnea, tachycardia and lung crackles in a client with heart failure indicate pulmonary edema, life threatening event. In pulmonary edema the left ventricle fails to eject sufficient blood, and pressure increases in the lungs because of the accumulated blood. Oxygen is always prescribed and the client is placed in high fowler's to ease the work of breathing. Furosemide, a rapid acting diuretic will eliminate accumulated fluid. A foley catheter is inserted to morphine sulfate reduces venous return (preload), decreases anxiety and reduces the work of breathing