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Which cardiovascular manifestations should the nurse anticipate for a pediatric client diagnosed with early compensated hypovolemic shock? Select all that apply. 1. Tachycardia 2. Weak distal pulses 3. Thready distal pulses 4. Normal blood pressure 5. Decrease in systolic blood pressure
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An infant with tetralogy of Fallot (TOF) is having a hypercyanotic episode ("tet" spell). Which nursing interventions are appropriate? Select all that apply. 1. Administer oxygen. 2. Place the child in knee-chest position. 3. Administer morphine and propranolol intravenously as ordered. 4. Draw blood for a serum hemoglobin. 5. Administer diphenhydramine (Benadryl) as ordered.
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Which treatment options should the nurse anticipate for a 10-month-old infant admitted to the emergency department with supraventricular tachycardia? Select all that apply. 1. Administering intravenous adenosine (Adenocard) 2. Administering intravenous amiodarone (Cardarone) 3. Preparing for cardioversion 4. Applying ice to the face 5. Having the child perform a Valsalva maneuver
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A child is admitted to the pediatric medical unit with a diagnosis of Kawasaki disease. Which provider prescription should the nurse question? 1. Contact isolation 2. Oral aspirin every 8 hours 3. Echocardiogram 4. Vital signs every 4 hours
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A school-age client is diagnosed with rheumatic fever. Which parental statement indicates the need for further education by the nurse? 1. "I understand rheumatic fever is a strep infection of the heart." 2. "My child will be on bed rest for several weeks." 3. "My child will be treated with aspirin and/or corticosteroids." 4. "Once my child has recovered, she will still need to be monitored for sequelae to the disease."
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Which feeding techniques should the nurse include in the teaching session for the parents of an infant who is being discharged in order to gain weight for the corrective surgery needed for a congenital heart defect? Select all that apply. 1. Breastfeed if possible. 2. Complete each feeding within 30 minutes. 3. Position the infant flat to promote swallowing. 4. Dilute the formula with extra water to ensure adequate fluid intake. 5. Burp the infant frequently.
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Which assessment data would cause the nurse to suspect that a pediatric client is experiencing hypovolemic shock? Select all that apply. 1. Dyspnea 2. Bradycardia 3. Tachycardia 4. Capillary refill time greater than 3 seconds. 5. Blood pressure 72/42 mmHg
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An infant who is diagnosed with a mild heart defect will not have surgical correction for at least 2 years. Which information should the nurse include in the discharge teaching regarding management in the home environment? 1. "Your child will have a low-grade fever until the defect is repaired." 2. "It is important for your child to maintain normal activity." 3. "Your child is not at risk for congestive heart failure." 4. "It is important to avoid antipyretics for the treatment of fever."
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Which assessment finding indicates adequate peripheral perfusion for a child after a cardiac catheterization? 1. Capillary refill is greater than 3 seconds. 2. Lower extremities are warm, with a capillary refill of less than 3 seconds. 3. Sensation is decreased with a weakened dorsalis pedis pulse. 4. Dorsalis pedis pulse is palpable but posterior tibial pulse is weak.
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Which is the priority nursing action when providing care to a pediatric client who is diagnosed with hypovolemic shock? 1. Assessing the cause of bleeding 2. Establishing an open airway and administering oxygen 3. Administering analgesics for pain control 4. Providing replacement of volume
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A 2-month-old infant with a congenital heart defect is admitted to the pediatric intensive care unit with congestive heart failure. Which intervention should the nurse include in the infant's plan of care? 1. Monitor respirations during active periods. 2. Give larger feedings less often to conserve energy. 3. Organize activities to allow for uninterrupted sleep. 4. Force fluids appropriate for age.
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Which heart defect should the nurse suspect for an infant whose upper extremities have stronger pulses than the lower extremities and blood pressure is higher in the arms than in the legs? 1. Transposition of the great vessels 2. Patent ductus arteriosus 3. Coarctation of the aorta 4. Atrial septal defect
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Which initial laboratory data does the nurse anticipate for a child who is admitted to the hospital with a cyanotic heart defect? 1. A low platelet count 2. A high white blood cell count 3. A high hemoglobin 4. A low hematocrit
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Which is the rationale the nurse provides to the parents of an infant diagnosed with congestive heart failure (CHF) for the prescribed spironolactone? 1. Produces rapid diuresis 2. Blocks reabsorption of sodium and water in renal tubules 3. Spares potassium 4. Promotes vascular relaxation
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Which parental statement regarding the use of cyclosporin A after a heart transplant indicate correct understanding of the information presented by the nurse? 1. "This medication is used to treat hypertension." 2. "This medication is used to reduce serum cholesterol level." 3. "This medication is used to prevent rejection." 4. "This medication is used to treat infections."
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The nurse is teaching a pregnant client about fetal circulation. Which is the correct sequence of blood flow that indicates the pregnant client understands the information presented? 1. Ductus arteriosus 2. Ductus venosus 3. Foramen ovale
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Which clinical manifestations does the nurse anticipate for a pediatric client who is diagnosed with the subacute stage of Kawasaki disease? Select all that apply. 1. High fever 2. Diarrhea 3. Thrombocytosis 4. Joint pain 5. Beau lines
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Which cardiovascular manifestations should the nurse anticipate for a pediatric client diagnosed with moderate uncompensated hypovolemic shock? Select all that apply. 1. Tachycardia 2. Weak distal pulses 3. Thready distal pulses 4. Normal blood pressure 5. Decrease in systolic blood pressure
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The nurse admits a child with a ventricular septal defect (VSD) to the pediatric unit. Which is the priority nursing diagnosis for this child? 1. Hypothermiarelated to decreased metabolic state 2. Acute Painrelated to the effects of a congenital heart defect 3. Ineffective Tissue Perfusion(peripheral) related to cyanosis secondary to congenital heart defect 4. Impaired Gas Exchangerelated to pulmonary congestion secondary to the increased pulmonary blood flow
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Which age-appropriate information should the nurse provide to a 4-year-old girl who is being emotionally prepared for open heart surgery? 1. The name of the surgeon who will be performing the procedure 2. What the surgical procedure will entail 3. The purpose of the heart-lung machine used during the procedure 4. What the environment will look and sound like when the child wakes up
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Which is an appropriate statement for the nurse to include in the discharge instructions to the parents of a child who is recovering from cardiac surgery? 1. "The child will have a fever for several weeks following the surgery." 2. "The child will be restricted from most play activities." 3. "The child will not receive routine immunizations." 4. "The child will receive prophylactic antibiotics prior to any dental procedures."
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Which laboratory test does the nurse anticipate for a child who is admitted to the hospital with suspected rheumatic fever? 1. Erythrocyte sedimentation rate 2. Throat culture 3. C-reactive protein 4. Antistreptolysin-O (ASO) titer
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Which teaching point should the nurse include in the discharge instructions for a pediatric client who has undergone cardiac surgery? 1. Should not receive routine immunizations. 2. Should be restricted from most play activities. 3. Fever is expected for several weeks following the surgery. 4. Prophylactic antibiotics are required for any dental, oral, or upper respiratory tract procedures.
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A toddler is prescribed digoxin (Lanoxin) for cardiac failure. Which should the nurse instruct the toddler's parents to monitor for as a manifestation associated with digoxin toxicity? 1. Bradycardia 2. Tinnitus 3. Ataxia 4. Hypotension
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Which athletic activity should the nurse recommend for a school-age child who is diagnosed with pulmonary artery hypertension? 1. Golf 2. Basketball 3. Cross-country running 4. Soccer
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Which clinical manifestation does the nurse anticipate for a pediatric client who is admitted with congestive heart failure (CHF)? 1. Tachycardia 2. Weight loss 3. Hypertension 4. Bradycardia
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Which is the priority action by the school nurse for an adolescent who drops to the ground and is unresponsive during a high school basketball game? 1. Initiating cardiopulmonary resuscitation (CPR) 2. Calling 911 3. Offering the parents comfort 4. Assessing for hemorrhage
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Which parental statement indicates correct understanding for the reason a cardiac catheterization is needed for a child who is diagnosed with a congenital heart defect? 1. "This procedure will keep the ductus arteriosus open and oxygenated and unoxygenated blood mixed." 2. "This procedure is used to close the ductus arteriosus to prevent mixing of arterial and venous blood." 3. "This procedure will redirect the blood so that blood bypasses the right ventricle." 4. "This procedure connects the ventricle to the atrium."
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Which strategies should the nurse recommend for a school-age client who is at risk for developing hypertension as an adult? Select all that apply. 1. Using seasoning substitutes for salt 2. Providing a list of foods high in sodium 3. Decreasing television time 4. Increasing physical activity 5. Monitoring blood pressure daily
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