Cardiac quiz
5. Discharge teaching for a 3-month-old infant with a cardiac defect who is to receive digoxin (Lanoxin) should include which of the following? Select all that apply. 1. Give the medication at regular intervals. 2. Mix the medication with a small volume of breast milk or formula. 3. Repeat the dose one time if the child vomits immediately after administration. 4. Notify the primary care provider of poor feeding or vomiting. 5. Make up any missed doses as soon as realized. 6. Notify the primary care provider if more than two consecutive doses are missed.
1, 4, 6. R: To achieve optimal therapeutic levels, digoxin should be given at regular intervals without variation, usually every 12 hours. Vomiting and poor feeding are signs of toxicity. If more than two consecutive doses are missed, interventions may be needed to assure therapeutic drug levels. The medication should not be mixed with any other fluid as refusal may result in inaccurate intake of the medication. Taking make-up doses, or taking the medication at times other than scheduled, may adversely affect serum levels.
14. As part of the preoperative teaching for the family of a child undergoing a tetralogy of Fallot repair, the nurse tells the family upon returning to the pediatric floor that the child may: 1. Be placed on a reduced sodium diet. 2. Have an activity restriction for several days. 3. Be assigned to an isolation room. 4. Have visits limited to a select few.
1. R: Because of the hemodynamic changes that occur with open heart surgery repair, particularly with septal defects, transient congestive heart failure may develop. Therefore, the child's sodium intake typically is restricted to 2 to 3 g/day. Activity restrictions are inappropriate. Typically the child is encouraged to walk the halls and unit. Risk for infection after the repair is the same as any postoperative client, therefore isolation is not necessary. The child may be placed in a room with other children who are not contagious. Visitors are not restricted unless the pediatric unit has restrictive visiting policies.
13. A child has had open heart surgery to repair a tetralogy of Fallot with a patch. The nurse should instruct the parents to: 1. Notify all health care providers before invasive procedures for the next 6 months. 2. Maintain adequate hydration of at least 10 glasses of water a day. 3. Provide for frequent rest periods and naps during the first 4 weeks. 4. Restrict the ingestion of bananas and citrus fruit.
1. R: Children who have undergone open heart surgery with a patch are at risk for infection, especially subacute bacterial endocarditis (SBE), for the first 6 months following surgery. The newest evidence-based guidelines suggest that once the patch has epithelialized, these precautions are no longer necessary. Therefore, parents are instructed about SBE precautions including the need to notify providers before invasive procedures so antibiotics can be prescribed for that time period. Having the child drink a very large amount of water may lead to fluid overload. Children gear their rest schedule to their activities making it unnecessary to schedule frequent rest periods. Bananas and citrus fruit are high in potassium, but there is no evidence provided that the child has an elevated serum potassium requiring restriction.
6. An 18-month-old with a congenital heart defect is to receive digoxin (Lanoxin) twice a day. The nurse should instruct the parents about which of the following? 1. Digoxin enables the heart to pump more effectively with a slower and more regular rhythm. 2. Signs of toxicity include loss of appetite, vomiting, increased pulse, and visual disturbances. 3. Digoxin is absorbed better if taken with meals. 4. If the child vomits within 15 minutes of administration, the dosage should be repeated.
1. R: Digoxin's effect is to slow the rate of the electrical conduction through the heart and increase the strength of the heart's contraction. Signs of toxicity include anorexia and decreased heart rate. Digoxin should be taken 1 hour before meals or 2 hours after meals in order to obtain better absorption of the drug. If the child vomits within 15 minutes of administration, the dose should not be repeated because it is not known how much of the medication has been absorbed.
21. Which of the following initial physical findings indicate the development of carditis in a child with rheumatic fever? 1. Heart murmur. 2. Low blood pressure. 3. Irregular pulse. 4. Anterior chest wall pain.
1. R: In rheumatic fever, the connective tissue of the heart becomes inflamed, leading to carditis. The most common signs of carditis are heart murmurs, tachycardia during rest, cardiac enlargement, and changes in the electrical conductivity of the heart. Heart murmurs are present in about 75% of all clients during the first week of carditis and in 85% of clients by the third week. Signs of carditis do not include hypotension or chest pain. The client may have a rapid pulse, but it is usually not irregular.
17. A 13-year-old has been admitted with a diagnosis of rheumatic fever and is on bed rest. He has a sore throat. His joints are painful and swollen. He has a red rash on his trunk and is experiencing aimless movements of his extremities. Use the chart below to determine what the nurse should do first. 1. Report the heart rate to the primary health care provider. 2. Apply lotion to the rash. 3. Splint the joints to relieve the pain. 4. Request a prescription for medication to treat the elevated temperature.
1. R: The child's heart rate of 150 bpm is significantly above its rate at the time of his admission. The nurse must notify the primary health care provider. The increase in heart rate may indicate carditis, a possible complication of rheumatic fever that can cause serious and life-long effects on the heart. The primary health care provider will intervene with medication and cardiac monitoring. While lotion may soothe the itching, the most important action for the nurse is to notify the primary health care provider of the increased heart rate. Splinting will not help the inflammation that is causing the painful joints. The painful joints migrate and will subside with time. The temperature is not elevated at this time, and does not require intervention.
19. A 12-year-old with rheumatic fever has a history of long-term aspirin use. Which statement by the client indicates that the nurse should notify the health care provider? 1. "I hear ringing in my ears." 2. "I put lotion on my itchy skin." 3. "My stomach hurts after I take that medicine." 4. "These pills make me cough."
1. R: Tinnitus is an adverse effect of prolonged aspirin therapy and the child should be examined by a health care provider for hearing loss. Itchy skin commonly accompanies the rash associated with rheumatic fever and the nurse can encourage lotion use. The nurse teaches clients to take aspirin with food or milk to avoid abdominal discomfort. The nurse can also address the fact that coughing after ingesting aspirin can be caused by inadequate fluid intake during administration.
25. A child with Kawasaki disease is receiving low dose aspirin. The mother calls the clinic and states that the child has been exposed to influenza. Which recommendations should the nurse make? Select all that apply. 1. Increase fluid intake. 2. Stop the aspirin. 3 .Keep the child home from school. 4. Watch for fever. 5. Weigh the child daily.
2, 4. R: Aspirin needs to be stopped because of its possible link to Reye syndrome. Additionally, the parents need to watch for signs and symptoms of influenza. Children with influenza frequently present with fever, cold symptoms, and gastrointestinal symptoms. Increasing the child's fluid intake and weighing the child daily are not needed at this time because the child is not ill. Keeping the child home from school is not necessary, because the child is not ill and has already been exposed.
16. The mother of a child hospitalized with tetralogy of Fallot tells the nurse that the child's 3-year-old sibling has become quiet and shy and demonstrates more than a usual amount of genital curiosity since this child's hospitalization. The nurse should tell the mother: 1. "This behavior is very typical for a 3-year-old." 2. "This may be how your child expresses feeling a need for attention." 3. "This may be an indication that your child may have been sexually abused." 4. "This may be a sign of depression in your child."
2. R: According to Erikson, the central psychosocial task of a preschooler is to develop a sense of industry versus guilt. Any environmental situation may affect the child. In this situation the sibling is probably feeling less attention from the mother and trying to resolve the conflict in an inappropriate way. Three-year-olds are usually active and outgoing. These behaviors represent a change. Data are not sufficient to suggest the child has been exposed to a sexual experience. Symptoms of depression would include withdrawal and fatigue.
22. The primary health care provider prescribes pulse assessments through the night for a 12-year-old child with rheumatic fever who has a daytime heart rate of 120. The nurse explains to the mother that this is to evaluate if the elevated heart rate is caused by: 1. The morning digitalis. 2. Normal activity during waking hours. 3. A warmer daytime environment. 4. Normal variations in day and evening hours.
2. R: An above-average pulse rate that is out of proportion to the degree of activity is an early sign of heart failure in a client with rheumatic fever. The sleeping pulse is used to determine whether the mild tachycardia persists during sleep (inactivity) or whether it is a result of daytime activities. The environmental temperature would need to be quite warmer before it could influence the heart rate. Digitalis lowers the heart rate, so the rate would be decreased during the daytime.
24. When developing the plan of care for a newly admitted 2-year-old child with the diagnosis of Kawasaki disease (KD), which of the following should be the priority? 1. Taking vital signs every 6 hours. 2. Monitoring intake and output every hour. 3. Minimizing skin discomfort. 4. Providing passive range-of-motion exercises.
2. R: Cardiac status must be monitored carefully in the initial phase of KD because the child is at high risk for congestive heart failure (CHF). Therefore, the nurse needs to assess the child frequently for signs of CHF, which would include respiratory distress and decreased urine output. Vital signs would be obtained more often than every 6 hours because of the risk of CHF. Although minimizing skin discomfort would be important, it does not take priority over monitoring the child's hourly intake and output. Passive range-of-motion exercises would be done if the child develops arthritis.
20. Which of the following outcomes indicates that the activity restriction necessary for a 7-year-old child with rheumatic fever during the acute phase has been effective? 1. Joints demonstrate absence of permanent injury. 2. The resting heart rate is between 60 and 100 bpm. 3. The child exhibits a decrease in chorea movements. 4. The subcutaneous nodules over the joints are no longer palpable.
2. R: During the acute phase of rheumatic fever, the heart is inflamed and every effort is made to reduce the work of the heart. Bed rest with limited activity is necessary to prevent heart failure. Therefore, the most reliable indicator that activity restriction has been effective is a resting heart rate between 60 and 100 bpm, normal for a 7-year-old child. No permanent damage to the joints occurs with rheumatic fever. The chorea movements associated with rheumatic fever are self-limited and usually disappear in 1 to 3 months. They are unrelated to activity restrictions. Subcutaneous nodules that occur over joint surfaces also resolve over time with no treatment. Therefore, they are not appropriate for evaluating the effectiveness of activity restrictions.
3. When teaching the parents of a child with a ventricular septal defect who is scheduled for a cardiac catheterization, the nurse explains that this procedure involves the use of which of the following? 1. Ultra-high-frequency sound waves. 2. Catheter placed in the right femoral vein. 3. Cutdown procedure to place a catheter. 4. General anesthesia.
2. R: In children, cardiac catheterization usually involves a right-sided approach because septal defects permit entry into the left side of the heart. The catheter is usually inserted into the femoral vein through a percutaneous puncture. Echocardiography involves the use of ultra-high-frequency sound waves. A cutdown procedure is rarely used. The catheterization is usually performed under local, not general, anesthesia with sedation.
2. A 4-year-old has been scheduled for a cardiac catheterization. To help prepare the family, the nurse should: 1. Advise the family to bring the child to the hospital for a tour a week in advance. 2. Explain that the child will need a large bandage after the procedure. 3. Discourage bringing favorite toys that might become associated with pain. 4. Explain that the child may get up as soon as the vital signs are stable.
2. R: The catheter insertion site will be covered with a bandage. This is important for preschool children to know as they are very concerned about bodily harm. The best time to prepare a preschool child for an invasive procedure is the night before. Bringing a favorite toy to the hospital will help decrease the child's anxiety. To prevent bleeding, the child will be expected to keep the extremity straight for 4 to 6 hours after the procedure, either in bed or on the parent's lap.
15. After surgery to correct a tetralogy of Fallot, the child's parents express concern to the nurse that their 4-year-old child wants to be held more frequently than usual. The nurse recommends: 1. Introducing a new skill. 2. Play therapy. 3. Encouraging the behavior. 4. Having the volunteer hold the child.
2. R: The child is exhibiting regression. During periods of stress, children frequently revert to behaviors that were comforting in earlier developmental stages; play therapy is one way to help the child cope with the stress. Teaching a new skill most likely would add more stress. Parents should be instructed to praise positive behaviors and ignore regressive behaviors rather than calling attention to them through encouragement or discouragement. Having someone else hold the child does not encourage coping with the stress or promoting appropriate development.
27. Which of the following should the nurse include when completing discharge instructions for the parents of a 12-month-old child diagnosed with Kawasaki disease (KD) and being discharged home? 1. Offer the child extra fluids every 2 hours for 2 weeks. 2. Take the child's temperature daily for several days. 3. Check the child's blood pressure daily until the follow-up appointment. 4. Call the primary health care provider if the irritability lasts for 2 more weeks.
2. R: The child's temperature should be taken daily for several days after discharge, because recurrent fever may develop. Offering the child fluids every 2 hours is not necessary. Doing so increases the child's risk for CHF. Checking the child's blood pressure at home usually is not included as part of the discharge instructions because, by the time of discharge, the child is considered stable and the risk for cardiac problems is minimal. Most children with KD recover fully. Irritability may last for 2 months after discharge.
12. An infant weighing 9 kg is in the pediatric intensive care unit following arterial switch surgery. In the past hour, the infant has had 16 mL of urine output. Which action should the nurse take? 1. Notify the primary health care provider immediately. 2. Record the urine output in the chart. 3. Administer a fluid bolus immediately. 4. Assess for other signs of hypervolemia.
2. R: Urine output for an infant weighing 9 kg should be 1 mL/kg/h. 16 mL of urine output is more than adequate for 1 hour so the nurse should record the output in the chart. There is no reason to notify the primary health care provider regarding adequate urine output. The infant has adequate output so there is no need for a fluid bolus. A fluid bolus could also cause the infant to become fluid overloaded, increasing the workload on the heart. There is no information in the question indicating that the child is hypervolemic.
10. When assessing a child after heart surgery to correct tetralogy of Fallot, which of the following should alert the nurse to suspect a low cardiac output? 1. Bounding pulses and mottled skin. 2. Altered level of consciousness and thready pulse. 3. Capillary refill of 2 seconds and blood pressure of 96/67 mm Hg. 4. Extremities warm to the touch and pale skin.
2. R: With a low cardiac output and subsequent poor tissue perfusion, signs and symptoms would include pale, cool extremities; cyanosis; weak, thready pulses; delayed capillary refill; and decrease in level of consciousness.
9. When teaching a preschool-age child how to perform coughing and deep-breathing exercises before corrective surgery for tetralogy of Fallot, which of the following teaching and learning principles should the nurse address first? 1. Organizing information to be taught in a logical sequence. 2. Arranging to use actual equipment for demonstrations. 3. Building the teaching on the child's current level of knowledge. 4. Presenting the information in order from simplest to most complex.
3. R: Before developing any teaching program for a child, the nurse's first step is to assess the child to determine what is already known. Most older preschool children have some understanding of a condition present since birth. However, the child's interest will soon be lost if familiar material is repeated too often. The nurse can then organize the information in a sequence, because there are several steps to be demonstrated. These exercises do not require the use of equipment. The nurse should judge the amount and complexity of the information to be provided, based on the child's current knowledge and response to teaching.
1. The nurse caring for a 7-year-old child who has undergone a cardiac catheterization 2 hours ago finds the dressing and bed saturated with blood. The nurse should first: 1. Assess the vital signs. 2. Reinforce the dressing. 3. Apply pressure just above the catheter insertion site. 4. Notify the primary health care provider.
3. R: Direct pressure is the first measure that should be used to control bleeding. Taking the vital signs will not control the bleeding. This should be done while another person is being sent to notify the primary health care provider. The dressing can be reinforced after the bleeding has been contained.
26. A 16-month-old child diagnosed with Kawasaki disease (KD) is very irritable, refuses to eat, and exhibits peeling skin on the hands and feet. The nurse should do which of the following first? 1. Apply lotion to the hands and feet. 2. Offer foods the toddler likes. 3. Place the toddler in a quiet environment. 4. Encourage the parents to get some rest.
3. R: One of the characteristics of children with KD is irritability. They are often inconsolable. Placing the child in a quiet environment may help quiet the child and reduce the workload of the heart. Although peeling of the skin occurs with KD, the child's irritability takes priority over applying lotion to the hands and feet. Children with KD usually are not hungry and do not eat well regardless of what is served. There is no indication that the parents need rest. Additionally, in this situation, the child takes priority over the parents.
4. When developing the discharge teaching plan for the parents of a child who has undergone a cardiac catheterization for ventricular septal defect, which of the following should the nurse expect to include? 1. Restriction of the child's activities for the next 3 weeks. 2. Use of sponge baths until the stitches are removed. 3. Use of prophylactic antibiotics before receiving any dental work. 4. Maintenance of a pressure dressing until a return visit with the primary health care provider.
3. R: Prophylactic antibiotics are suggested for children with heart defects before dental work is done to reduce the risk of bacterial infection. Typically, activities are not restricted after a cardiac catheterization. A percutaneous approach is used to insert the catheter, so stitches are not necessary. Showering or bathing is allowed as usual. The pressure dressing will be removed before the child is discharged.
18. A nurse is planning care for a 12-year-old with rheumatic fever. The nurse should teach the parents to: 1. Observe the child closely. 2. Allow the child to participate in activities that will not tire him. 3. Provide for adequate periods of rest between activities. 4. Encourage someone in the family to be with the child 24 hours a day.
3. R: The nurse should teach the parents to provide for sufficient periods of rest to decrease the client's cardiac workload. The client's condition does not warrant close observation unless cardiac complications develop. The child's activity level will be based on the results of the sedimentation rate, c-reactive protein, heart rate, and cardiac function. The family does not need to be with the client 24 hours a day unless carditis develops and his condition deteriorates.
7. Twelve hours after cardiac surgery, the nurse is assessing a 3-year-old who weighs 15 kg. The nurse should notify the surgeon about which of the following clinical findings? 1. A urine output of 60 mL in 4 hours. 2. Strong peripheral pulses in all four extremities. 3. Fluctuations of fluid in the collection chamber of the chest drainage system. 4. Alterations in levels of consciousness.
4. R: Clinical signs of low cardiac output and poor tissue perfusion include pale, cool extremities, cyanosis or mottled skin, delayed capillary refill, weak, thready pulses, oliguria, and alterations in level of consciousness. An adequate urine output for a child over 1 year should be 1 mL/kg/h. Therefore 60 mL/4 h is satisfactory. Strong peripheral pulses indicate adequate cardiac output. Drainage from the chest tube should show fluctuation in the drainage compartment of the chest drainage system. The fluid level normally fluctuates as proof that the apparatus is airtight. On about the 3rd postoperative day, the fluctuation ceases indicating the lungs have fully expanded.
23. Which of following should the nurse perform to help alleviate a child's joint pain associated with rheumatic fever? 1. Maintaining the joints in an extended position. 2. Applying gentle traction to the child's affected joints. 3. Supporting proper alignment with rolled pillows. 4. Using a bed cradle to avoid the weight of bed linens on joints.
4. R: For a child with arthritis associated with rheumatic fever, the joints are usually so tender that even the weight of bed linens can cause pain. Use of a bed cradle is recommended to help remove the weight of the linens on painful joints. Joints need to be maintained in good alignment, not positioned in extension, to ensure that they remain functional. Applying gentle traction to the joints is not recommended because traction is usually used to relieve muscle spasms, not typically associated with rheumatic fever. Supporting the body in good alignment and changing the client's position are recommended, but these measures are not likely to relieve pain.
11. Which of the following is the greatest priority for the therapeutic management of a child with congestive heart failure (CHF) caused by pulmonary stenosis? 1. Educating the family about the signs and symptoms of infection. 2. Administering enoxaparin (Lovenox) to improve left ventricular contractility. 3. Assessing heart rate and blood pressure every 2 hours. 4. Administering furosemide (Lasix) to decrease systemic venous congestion.
4. R: Pulmonary stenosis can cause right-sided CHF, resulting in venous congestion. Removing accumulated fluid is a primary goal of treatment in right-sided CHF. Lasix is used to reduce venous congestion. It is important to educate the family about signs and symptoms of CHF but treating the client's CHF is the priority. Lovenox is an anticoagulant and will not help improve left ventricular contractility. It is important to assess vital signs frequently in the child with CHF but assessments do not treat the problem.
8. A child diagnosed with tetralogy of Fallot becomes upset, crying and thrashing around when a blood specimen is obtained. The child's color becomes blue and the respiratory rate increases to 44 breaths/min. Which of the following actions should the nurse do first? 1. Obtain a prescription for sedation for the child. 2. Assess for an irregular heart rate and rhythm. 3. Explain to the child that it will only hurt for a short time. 4. Place the child in a knee-to-chest position.
4. R: The child is experiencing a tet or hypoxic episode. Therefore the nurse should place the child in a knee-to-chest position. Flexing the legs reduces venous flow of blood from the lower extremities and reduces the volume of blood being shunted through the interventricular septal defect and the overriding aorta in the child with tetralogy of Fallot. As a result, the blood then entering the systemic circulation has higher oxygen content, and dyspnea is reduced. Flexing the legs also increases vascular resistance and pressure in the left ventricle. An infant often assumes a knee-to-chest position in the crib, or the mother learns to put the infant over her shoulder while holding the child in a knee-to-chest position to relieve dyspnea. If this position is ineffective, then the child may need a sedative. Once the child is in the position, the nurse may assess for an irregular heart rate and rhythm. Explaining to the child that it will only hurt for a short time does nothing to alleviate the hypoxia.
