Cardiovascular/Critical Care Concepts/Basic Care & Comfort

A 3-month-old infant has irritability, facial edema, a 1-day history of diarrhea with adequate oral intake, and seizure activity. During assessment, the parents state that they have recently been diluting formula to save money. Which is the most likely cause for the infant's symptoms? 1. Hypernatremia due to diarrhea. 2. Hypoglycemia due to dilute formula intake. 3. Hypokalemia due to excess gastrointestinal output. 4. Hyponatremia due to water intoxication.

4. Hyponatremia due to water intoxication.

The nurse receives 4 prescriptions for a child diagnosed with hemophilia A who was brought to the emergency department following an injury on the school playground. The child has vomited once and has a headache. Which prescription should the nurse carry out first? 1. Administer IV factor VIII. 2. Administer IV ondanestron. 3. Blood draw for hemoglobin. 4. CT scan of the head.

1. Administer IV factor VIII.

An 8-month-old infant is scheduled for a balloon angioplasty of a congenital pulmonic stenosis in the cardiac catheterization laboratory. Which finding should the nurse report to the health care provider (HCP) that could possibly delay the procedure? 1. Auscultation of a loud heart murmur. 2. Infant has been NPO for 4 hours. 3. Infant has polycythemia. 4. Infant has severe diaper rash.

4. Infant has severe diaper rash.

A 3-month-old who weighs 8.8 lb (4 kg) has just returned to the intensive care unit after surgical repair of a congenital heart defect. Which finding by the nurse should be reported immediately to the health care provider (HCP)? 1. Chest tube output of 30 mL in the past hour. 2. Heart rate of 180/min. 3. Temperature of 97.5 F (36.4 C). 4. Urine output of 12 mL in the past hour.

1. Chest tube output of 30 mL in the past hour.

The home health nurse is visiting an infant who recently had surgery to repair tetralogy of Fallot. The nurse should teach the parents to report which findings indicative of heart failure to the health care provider (HCP)? Select all that apply. 1. Cool extremities. 2. Increase in appetite. 3. Puffiness around the eyes. 4. Reduction in number of we diapers. 5. Weight loss.

1. Cool extremities. 3. Puffiness around the eyes. 4. Reduction in number of we diapers.

The nurse is providing discharge instructions to the parent of a child with Kawasaki disease. The nurse informs the parent that the presence of which symptom should be immediately reported to the health care provider? 1. Fever 2. Irritability 3. Knee pain 4. Skin peeling

1. Fever

The nurse who is caring for a 1-month-old with Tetralogy of Fallot will report which finding to the health care provider as a priority? 1. Hemoglobin level of 24.9 g/dL (249 g/L). 2. Murmur on heart auscultation. 3. Oxygen saturation of 82% on room air. 4. Poor weight gain.

1. Hemoglobin level of 24.9 g/dL (249 g/L).

The nurse is planning care for a child being admitted with Kawasaki disease and should give priority to which nursing intervention? 1. Apply cool compresses to the skin of the hands and feet. 2. Monitor for a gallop heart rhythm and decreased urine output. 3. Prepare a quiet, non-stimulating, and restful environment. 4. Provide soft foods and liberal amounts of clear liquids.

2. Monitor for a gallop heart rhythm and decreased urine output.

A nurse auscultates a loud cardiac murmur on a newborn with suspected trisomy 21 (Down syndrome). A genetic screen and an echocardiogram are scheduled that day. The neonate's vital signs are shown in the exhibit. What would be an appropriate action for the nurse to complete next? Click on the exhibit button for additional information. 1. Call the health care provider (HCP) immediately. 2. Document the assessment finding. 3. Place the neonate in a knee-chest position. 4. Provide oxygen to the neonate.

2. Document the assessment finding.

A nurse is assessing a 1-month-old infant with an atrial septal defect (ASD). Which assessment finding does the nurse expect? 1. Muffled heart tones. 2. Murmur. 3. Cyanosis. 4. Weak femoral pulses.

2. Murmur.

The nurse is caring for a newborn with patent ductus arteriosus. Which assessment finding should the nurse expect? 1. Harsh systolic murmur. 2. Loud machine-like murmur. 3. Soft diastolic murmur. 4. Systolic ejection murmur.

2. Loud machine-like murmur.

Several clients check into the emergency department at the same time. Which client should be seen first? 1. 6-year old with blood-streaked stools. 2. 10-year old with epilepsy who had a short seizure at home and is asleep. 3. 15-year old with dental trauma and tooth avulsion. 4. Newborn who spits up after every feed.

3. 15-year old with dental trauma and tooth avulsion.

When monitoring an infant with a left-to-right-sided heart shunt, which findings would the nurse expect during the physical assessment? Select all that apply. 1. Clubbing of fingertips. 2. Cyanosis when crying. 3. Diaphoresis during feedings. 4. Heart murmur. 5. Poor weight gain.

3. Diaphoresis during feedings. 4. Heart murmur. 5. Poor weight gain.

The nurse is caring for a child with Kawasaki disease who is receiving IV immunoglobulin. The child's parent wants to know why this treatment is required. The nurse explains that this therapy is given to: 1. Fight the infection. 2. Minimize rash. 3. Prevent heart disease. 4. Reduce spleen size.

3. Prevent heart disease.

The parent of a 3-year-old calls and tells the nurse of finding the child in the bathroom with an empty bottle of mouthwash. The parent thinks that the bottle was about one quarter full. What is the nurse's priority response? 1. "Call the poison control center. I will give you the number." 2. "Give your child about a cup of water to dilute the mouthwash." 3. "How did your child get hold of the mouthwash?" 4. "What is your child doing right now?"

4. "What is your child doing right now?"

The nurse in the pediatric clinic is triaging telephone messages. The nurse should call the parent of which child first? 1. 2-year old with bilateral tympanostomy tubes who has a small piece of plastic in the right outer ear. 2. 4-year old post adenotonsillectomy who is now reporting ear pain. 3. 6-year old with step throat who needs a note to return to school 24 hours after starting antibiotics. 4. 7-year old 5 days post tonsillectomy who wants to return to soccer practice today.

4. 7-year old 5 days post tonsillectomy who wants to return to soccer practice today.

The nurse has received report on 4 pediatric clients. Which client should the nurse assess first? 1. Client with coarctation of the aorta and diminished femoral pulses. 2. Client with patent ductus arteriosus and a loud machinery-like murmur. 3. Client with tetralogy of Fallot and oxygen saturation of 80% on room air. 4. Client with ventricular septal defect; tachypnea and diaphoresis during feedings.

4. Client with ventricular septal defect; tachypnea and diaphoresis during feedings.

A nurse is assisting a new mother as she is breastfeeding her infant. The infant has been diagnosed with tetralogy of Fallot. During feeding, the infant becomes cyanotic and is having difficulty breathing. What should be the nurse's first action? 1. Administer morphine to the infant. 2. Administer oxygen via mask. 3. Assess infant's vital signs and pulse oximetry. 4. Place the infant in the knee-chest position.

4. Place the infant in the knee-chest position.

A nurse is caring for a 6-year-old who had a cardiac catheterization. During assessment of the groin site, the nurse notices that the dressing is saturated with blood and a small trickle leaks down the child's leg. What should the nurse's first action be? 1. Apply a new pressure dressing to the catheterization site. 2. Call the health care provider. 3. Check the peripheral pulse distal to the catheterization site. 4. Remove the dressing and apply direct pressure above the puncture site.

4. Remove the dressing and apply direct pressure above the puncture site.