Chapter 19 Cardiovascular disorder
A group of students are reviewing information about acute rheumatic fever. The students demonstrate a need for additional review when they identify which of the following as a major Jones criterion? A. Arthralgia B. Subcutaneous nodules C. Erythema marginatum D. Carditis
A Arthralgia is considered a minor criterio
The nurse is assessing an infant for peripheral edema. Based on the nurse's knowledge, the nurse would expect edema to occur in which area first? A. Face B. Upper extremities C. Lower extremities D. Presacral region
A In infants, peripheral edema occurs first in the face, then the presacral region, and then the extremities. Edema of the lower extremities is characteristic of right ventricular heart failure in older children.
After a cardiac catheterization, the nurse monitors the child's fluid balance closely based on the understanding of which of the following? A. The contrast material used has a diuretic effect. B. Blood loss during the procedure can be significant. C. The prolonged preprocedure fasting state places the child at risk for dehydration. D. The insertion of the catheter into the heart stimulates a diuretic response.
A The contrast material has a diuretic effect so the nurse assesses the child closely for signs and symptoms of dehydration and hypovolemia
After assessing a child, the nurse suspects coarctation of the aorta based on which of the following? A. Narrow pulse B. Bounding pulse C. Femoral pulse weaker than brachial pulse D. Hepatomegaly
C A femoral pulse that is weak or absent in comparison to the brachial pulse is associated with coarctation of the aorta
The nurse is caring for a 14-year-old girl with atrial fibrillation. Which medication would the nurse expect to be prescribed? A. Alprostadil B. Indomethacin C. Digoxin D. Furosemide
C Digoxin is indicated for atrial fibrillation. It increases the contractility of the heart muscle by decreasing conduction and increasing force.
The nurse is assessing the blood pressure of a toddler. Which finding would the nurse document as a normal finding? A. 80/40 mm Hg B. 100/60 mm Hg C. 110/60 mm Hg D. 90/64 mm Hg
D The toddler's or preschooler's blood pressure averages 80 to 100/64 mm Hg.
When developing a teaching plan for the parents of a child diagnosed with tricuspid atresia, the nurse would integrate knowledge of which of the following as the major mechanism involved? A. Obstruction of blood flow to the lungs B. Mixing of well-oxygenated and poorly oxygenated blood C. Narrowing of the major vessel D. Increased pulmonary blood flow
A Tricuspid atresia is a congenital heart defect in which the valve between the right atrium and right ventricle fails to develop, resulting in no opening to allow blood to flow from the right atrium to the right ventricle and subsequently through the pulmonary artery into the lungs. It is classified as a disorder of decreased pulmonary blood flow due to obstruction of blood flow to the lungs
The nurse is reviewing the health history and physical examination of a child diagnosed with heart failure. Which of the following would the nurse expect to find? Select all that apply. A. Crackles on lung auscultation B. Tiring easily when eating C. Shortness of breath when playing D. Hypertension E. Bradycardia
A, B, C Manifestations of heart failure include difficulty feeding or eating or becoming tired easily when feeding or eating, shortness of breath with exercise intolerance, crackles and wheezes on lung auscultation, tachycardia, and hypotension.
An 8-year-old girl, who is complaining of a "really bad" sore throat and whose temperature is 102.2°F, is seen in the school nurse's o ce. e nurse has the child lie down in a room away from other children. Which of the following statements is most important for the nurse to convey when calling the child's parents? 1. "Your child should be seen by her primary care provider." 2. "Your child is very uncomfortable with a sore throat." 3. "Your child is crying and asking for mommy and daddy." 4. "Your child may be contagious to the other children."
ANSWER: 1 Rationale: 1. is is the most important statement. e child may have a group A strep infection that will need to be treated. 2. is is an important statement but not the most important. 3. is is an important statement but not the most important. 4. is is an important statement but not the most important. TEST-TAKING TIP: Anytime a test question includes the word "most," all of the actions in the responses are correct. The examiner, however, is asking the test-taker to pick the one best response to the question. Because any infection caused by group A strep that is untreated may result in the child developing rheumatic fever, the nurse must advise the parents to have their child assessed by the child's primary health-care provider.
A child with Kawasaki disease is to receive IV immune globulin on day 7 of the illness. A parent asks the nurse, "I am so scared. Will my child be cured a er getting the medicine?" Which of the following responses by the nurse is appropriate? 1. "I cannot promise, but children have been shown to have the best results from the medicine when it is given before the 10th day of the illness." 2. "I am sure that your child will be ne. is medicine has been shown to work well for children with Kawasaki disease." 3. "I really do not know. We will nd out more when your child has follow up testing in 1 or 2days." 4. "I know that you are scared, but it is important for you to have faith in your doctors because they are doing all that they can do."
ANSWER: 1 Rationale: 1. is is an appropriate response for the nurse to give. e nurse is providing correct information without making false promises. 2. Even when immune globulin is administered, some children still develop aneurysms. e nurse should not give the mother promises that may not be correct. 3. is statement dismisses the mother's question. If the nurse is uncertain regarding what the answer should be, he or she should have someone with knowledge speak with the mother. 4. is statement does not answer the mother's question. Having trust in the health-care providers is not the issue. e child's health is the issue. TEST-TAKING TIP: Nurses must communicate to parents honestly but with compassion. It is inappropriate to give parents false promises, but to provide them with realistic hope for a successful outcome is appropriate.
A 12-year-old child has been diagnosed with group A strep pharyngitis. e primary health-care provider has ordered penicillin V 500 mg PO tid for 10 days. Which of the following questions is important for the nurse to ask the parents and the child before giving them the prescription? 1. "Is there any reason why you will not be able to take medicine 3 times a day for 10 days?" 2. "Would you rather get 1 shot or take 40 pills?" 3. "Have you ever had strep throat before?" 4. "Do you know of any other children in your school who have recently had sore throats?"
ANSWER: 1 Rationale: 1. It is important to be sure that the child will receive the entire 10 days of medication. If the parents or child state that they will be unable to complete the prescribed medication, the nurse should notify the ordering practitioner and suggest that an injection of penicillin G benzathine be administered instead. 2. is question is a poor way for the nurse to determine whether it would be best to administer the penicillin orally or parenterally. 3. e nurse should ask the parents and child whether this is the rst bout of strep A or whether the child has had the infection previously. at information, however, is unrelated to providing them with the prescription. 4. Noting whether other children have had sore throats is unrelated to providing the child and parents with the medication prescription. TEST-TAKING TIP: If either the parents or the child indicates an unwillingness or inability to complete the full course of oral antibiotics, the nurse should suggest to the ordering practitioner that it would be best to administer an injection. Because only one injection of penicillin G is needed, the nurse and ordering health-care practitioner can then be assured that the child's infection will be treated adequately.
A toddler with Kawasaki disease is to receive IV immune globulin. Which of the following actions must the nurse perform? Select all that apply. 1. Discard the immune globulin if it appears cloudy. 2. Check the expiration date of the immune globulin. 3. Secure the arm to the arm board with a clear shield. 4. Document the lot number of the infusion in the child's medical record. 5. Allow the refrigerated immune globulin to warm in the microwave for 1 full minute.
ANSWER: 1, 2, 3, and 4 Rationale: 1. Immune globulin should be clear with no cloudiness or sediment. If either is present, the solution should be discarded. 2. It is essential for nurses to check the expiration date of any medication administered to patients. 3. Toddlers may unintentionally injure an IV site. To maintain its patency, therefore, the arm should be taped to an arm board, and a clear shield should be placed above the site for easy inspection. 4. e lot number of the immune globulin should be documented in case serious side e ects occur. All other bags of that lot number can then be examined and/or destroyed. 5. If the immune globulin has been refrigerated, it should be warmed. e only safe way to warm the solution, however, is to leave it at room temperature for 30 min. e solution should never be placed in the microwave. TEST-TAKING TIP: Administering immune globulin requires similar safety practices as those performed when administering blood products. Although no matching of blood type is involved as it is when blood is infused, there is a potential for allergic responses and other signs/symptoms seen in transfusion reactions (e.g., flank pain and elevated temperature).
A child who has been diagnosed with chorea has been admitted to the pediatric unit with a diagnosis of rheumatic fever. Immediately prior to admission, the child's throat culture was positive for group A strep. Which of the following actions should the nurse perform when admitting the child? Select all that apply. 1. Cover the headboard with a so material. 2. Put the child on droplet precautions. 3. Place a tracheostomy tray in the child's room. 4. Have the child perform active range of motion exercises. 5. Assess the child's apical heart rate for one full minute.
ANSWER: 1, 2, and 5 Rationale: 1. A child with chorea from RF should be placed on seizure precautions. e headboard should be covered. 2. e child's throat culture is positive for group A strep. e child should be placed on droplet isolation until he or she has received a full 24 hr of medication. 3. ere is no need to place a trach tray in the child's room. Tracheal occlusion is a rare complication of strep pharyngitis. 4. It is inappropriate to have the child perform active ROM exercises. e child may have carditis and/or polyarthritis. ROM exercises could aggravate either of the manifestations of the disease. 5. e nurse should assess the child's apical pulse for 1 full minute to assess whether or not a murmur is present. A murmur would indicate that the child likely has carditis. TEST-TAKING TIP: This is a multiple response item. Each of the items should be reviewed independently to determine which of them is related to the stem of the question. Because the child in the scenario has been diagnosed with RF and has been found to have a positive culture for group A strep, responses 1, 2, and 5 are correct.
A baby that was born 5 minutes earlier is tachypneic, tachycardic, and markedly cyanotic. A STAT echocardiogram con rms the presence of a cyanotic congenital cardiac defect. Which of the following defects would be consistent with the assessment endings? 1. Patent ductus arteriosus 2. Transposition of the great vessels 3. Atrial septal defect 4. Ventricular septal defect
ANSWER: 2 Rationale: 1. PDA is an acyanotic defect that results in a le -to-right shunt. 2. Transposition of the great vessels (TGV) is a cyanotic defect. Unless another defect is also present, the defect is incompatible with life. 3. ASD is an acyanotic defect that results in a le -to-right shunt. 4. VSD is an acyanotic defect that results in a le -to-right shunt. TEST-TAKING TIP: The only cyanotic defect listed is TGV. If the test-taker were not to know that fact, however, he or she could deduce the correct response. Septal defects and PDAs result in left-to-right shunts, resulting in the blood reentering the pulmonary system in which it is oxygenated.
A 21⁄2-year-old child is in the hospital with Kawasaki disease. Which of the following actions by the nurse is important for the child's psychosocial care? 1. Place the child in a single-bedded room. 2. Make sure the child always has his transitional object with him. 3. Supply the child with board games for play. 4. Let the child see what he looks like in a surgical mask and cap.
ANSWER: 2 Rationale: 1. A single-bedded room is not indicated in this situation and will not help to promote the psychosocial well-being of the toddler. 2. Transition objects (e.g., blankets, dolls, paci ers) help toddlers to deal with stressful situations. Unless medically contraindicated, nurses should make sure that young children are in possession of their transition objects at all times while in the hospital. 3. Toddlers usually engage in parallel play. ey rarely play with board games. 4. ere is no reason to have the child wear a surgical mask. Kawasaki disease is not contagious and children with Kawasaki rarely need surgery. TEST-TAKING TIP: When caring for children, nurses must consider not only their physiological illness, but also the child's growth and development needs. Toddlers engage in parallel play and often are strongly attached to transition objects.
A baby, exhibiting no obvious signs of congestive heart failure, has been diagnosed with a small ventricular septal defect. Which of the following information should the nurse explain to the baby's parents? 1. The baby will likely need open-heart surgery within a week. 2. The defect will likely close without therapy. 3. The defect likely developed early in the second trimester. 4. The baby will likely be placed on high-calorie formula.
ANSWER: 2 Rationale: 1. e majority of small VSDs close spontaneously. Surgery is performed only when babies' defects fail to close and/or if signs and symptoms of CHF develop. 2. e majority of small VSDs close spontaneously. 3. e heart is formed early in fetal development—by the 8th week of gestation. 4. Babies usually are maintained on a normal diet—either breast milk, if the mother is breastfeeding, or over-the- counter formula. TEST-TAKING TIP: The vast majority of babies with VSDs are discharged from the well-baby nursery and are seen periodically by a cardiologist on an outpatient basis. This can be frightening to the parents who are told that their baby has a hole in his or her heart. It is important, therefore, for the nurse to reassure the parents that most VSDs do close spontaneously. However, the nurse must educate the parents regarding signs of CHF in case the baby does begin to go into cardiac failure.
A nurse is educating the parents of a child with an atrial septal defect regarding the child's condition. Which of the following information would be appropriate for the nurse to provide? 1. The baby becomes cyanotic because the blood is owing through a hole from the right side of the heart to the le side of the heart. 2. The baby has a murmur because there is a hole between the aorta and the pulmonary artery. 3. The baby's heart is working harder than a normal heart because some of its blood is reentering the pulmonary system. 4. The baby's heart rate is slowed because of the high number of red blood cells in the blood
ANSWER: 3 Rationale: 1. An ASD is an acyanotic defect. If the child should develop cyanosis, which is rare unless the defect is very large, the symptom is not due to a right-to-le shunt. In the case of an ASD, the blood ows through the defect from le to right. 2. e murmur heard when a baby has an ASD is due to blood moving through the septal defect. A hole between the pulmonary artery and the aorta is a patent ductus arteriosus (PDA). 3. is response is correct. In the case of an ASD and other acyanotic defects, the blood is reentering the pulmonary system as a result of le to right shunting. 4. Babies with ASDs usually have normal heart rates. If they do go into CHF, however, they would exhibit tachycardia rather than bradycardia. Elevated RBC counts are seen in babies with cyanotic defects as a result of chronic hypoxia. TEST-TAKING TIP: Left-to-right shunt refers to the path the blood takes through the heart. When there is a hole in the heart—ASD, VSD, or PDA—the blood travels from the left side to the right side simply because the left ventricle is stronger than the right ventricle. Because the blood travels repeatedly into the right ventricle, it enters the pulmonary system repeatedly via the pulmonary artery. In some cyanotic diseases, most notably Tetralogy of Fallot, the blood travels from the right side of the heart to the left side. This occurs in Tetralogy of Fallot because the stenotic pulmonic valve prevents the blood from entering the pulmonary artery. Rather the blood is "shunted" through the overriding aorta, thereby bypassing the lungs.
A nurse is assessing a 1-day-old sleeping baby in the well-baby nursery. Which of the following assessments should the nurse report to the neonatologist? 1. Temperature 97.9°F 2. Blood pressure 77/46 3. Respiratory rate 52 4. Apical heart rate 179
ANSWER: 3 Rationale: 1. e temperature of 97.9°F is normal in a neonate. 2. e blood pressure of 77/46 mm Hg is normal in a neonate. 3. e respiratory rate of 52 is normal in a neonate. 4. e normal heart rate in a newborn is 110 to 160 bpm. A rate of 179 is well above normal. TEST-TAKING TIP: Tachycardia in a neonate may indicate the presence of cardiac disease.
A 10-year-old child is in the hospital on bedrest with a diagnosis of rheumatic fever complicated by carditis. When the nurse responds to the child's call bell, the child states, "I hate this! I want to get up and play!" Which of the following responses is appropriate for the nurse to make at this time? 1. "I know that you are unhappy, but you must stay in bed so that you can get better and go home." 2. "What if we make a deal and I promise to let you get up for 10 minutes every 2 hours if you are very good the rest of the day?" 3. "I am sure that I can get the doctor to let you go to the playroom for 1 to 2 hours this a ernoon." 4. "I am so sorry that you are unhappy, but what if I contact the play lady and have her bring you a selection of video games to play with?"
ANSWER: 4 Rationale: 1. Although accurate, the statement is not supportive of the young child's frustration with having to remain on bedrest. ere is a much better response. 2. is response is not appropriate. e activity may be damaging to the child's heart. 3. is response is not appropriate. e doctor may not allow the child to go to the playroom, even if transported in the hospital bed. e child, then, may not trust the nurse a er the promise has been broken. 4. is is an appropriate statement. e nurse is empathetic and is o ering a realistic solution to the child's unhappiness. TEST-TAKING TIP: It is important for nurses to be honest with children. When a promise is made to a child and not kept, the child often will not trust any future statements the caregiver makes.
A child has been diagnosed with Kawasaki disease. Which of the following signs and symptoms would the nurse expect to see? Select all that apply. 1. Diarrhea 2. Vertigo 3. Purpural rash over torso 4. Reddened and crusty eyes 5. Skin peeling from hands and feet
ANSWER: 4 and 5 Rationale: 1. Diarrhea is not a classic symptom of Kawasaki disease. 2. Vertigo is not a classic symptom of Kawasaki disease. 3. Purpural rash is not a classic sign of Kawasaki disease. 4. Children with Kawasaki disease do have conjunctivitis. 5. e palms and soles of children with Kawasaki do desquamate. TEST-TAKING TIP: Kawasaki disease is diagnosed from a series of signs and symptoms, including prolonged fever, conjunctivitis, strawberry tongue, rash on the palms and soles that desquamates, and cardiac changes.
A 6-year-old girl had a cardiac catheterization at 9 a.m. At 11 a.m. the nurse notes hypotension as compared to baseline. Based on this assessment finding, which of the following would the nurse do first? A. Check the toes' capillary refill. B. Check the insertion site. C. Recheck the blood pressure every 15 minutes. D. Assess the child's temperature.
B Hypotension may signify hemorrhage due to perforation of the heart muscle or bleeding from the insertion site.
The nurse is assessing a child with aortic stenosis. Which of the following would the nurse most likely assess? Select all that apply. A. Blood pressure in arms significantly higher than in legs B. Chest pain with activity C. Moderately loud systolic murmur at the base of the heart D. Dizziness with prolonged standing E. Thrill palpated at base of heart
B, D, E Assessment findings associated with aortic stenosis include angina or chest pain with activity, dizziness with prolonged standing, and a thrill palpated at the base of the heart. A moderately loud systolic murmur at the base of the heart and blood pressure that is significantly higher in the arms than in the legs, possibly 20 mm Hg or higher, suggests coarctation of the aorta.
The nurse is taking a health history of a toddler with a suspected congenital heart defect. Which of the following responses by the mother could indicate that the child is experiencing hypercyanotic spells? A. "He does not seem to have difficulty breathing." B. "He takes one nap a day and is fairly active." C. "He likes to stop and squat wherever he walks." D. "He walks very quickly and never stops moving."
C The walking toddler may squat periodically to relieve a hypercyanotic spell. This position serves to improve pulmonary blood flow by increasing systemic vascular resistance.
The nurse is caring for a 10-year-old girl with a suspected heart arrhythmia. The nurse would expect to prepare the child for which test to identify and quantitate the arrhythmia? A. Chest radiograph B. Echocardiogram C. Arteriogram D. Ambulatory electrocardiographic monitoring
D Ambulatory electrocardiographic monitoring is indicated to identify and quantitate arrhythmias in a 24-hour period during normal daily activities
The nurse is taking a health history of a 6-week-old boy with a suspected cardiovascular disorder. Which of the following responses by the mother would lead the nurse to suspect that the child is experiencing heart failure? A. "He seems to have a normal appetite." B. "He does not seem sick." C. "He does not seem short of breath." D. "He gets sweaty when he eats."
D Diaphoresis with nipple feeding indicates heart failure
The nurse is caring for a 10-year-old boy following a cardiac catheterization. Four hours after the procedure, the nurse notes some minor bleeding at the site. Which action would be most appropriate? A. Contact the physician. B. Change the dressing. C. Ensure that the child's leg is kept straight. D. Apply pressure 1 inch above the site.
D If bleeding occurs after a cardiac catheterization, apply pressure 1 inch above the site to create pressure over the vessel, thereby reducing the blood flow to the area.
An 8-year-old child is scheduled for an exercise stress test. Which instruction would be most important for the nurse to emphasize? A. "You need to lie very still during this test." B. "You'll have to wear the monitor for 24 hours." C. "You get some medicine that will make you sleepy." D. "You need to report any symptoms you are having during the test."
D It is important for the child to report any symptoms felt during the test to help quantify the child's exercise tolerance.
The nurse assesses a child for clubbing. Which of the following would the nurse identify as the initial sign? A. Rounding of the fingers B. Shininess of the nail ends C. Thickening of the nail ends D. Softening of the nail beds
D The first sign of clubbing is softening of the nail beds followed by rounding of the fingernails, followed by shininess and thickening of the nail ends.
The nurse is caring for a 6-year-old child with a congenital heart defect. To best relieve a hypercyanotic spell, what action would be the priority? A. Provide supplemental oxygen. B. Administer propranolol (0.1 mg/kg IV). C. Use a calm, comforting approach. D. Place the child in a knee-to-chest position.
D The priority nursing action is to place the infant or child in a knee-to-chest position. Once the child has been placed in this position, the nurse should provide supplemental oxygen or administer medication as ordered.
The neonatal cardiologist orders digoxin (Lanoxin) for a newborn in congestive heart failure. e baby weighs 7 lb 8 oz and is 21 inches long. e drug reference states: for full-term newborns, 8 to 10 mcg/kg/day in divided doses every 12 hr. Which of the following orders would be safe for the nurse to administer? 1. 10mcgPOevery12hr 2. 15mcgPOevery12hr 3. 20mcgPOevery12hr 4. 25mcgPOevery12hr
NSWER: 2 Rationale: 1. Ten mcg PO every 12 hr is below the recommended dosage range for digoxin. 2. Fi een mcg PO every 12 hr is between the minimum and the maximum recommended dosages for digoxin and is the correct response. 3. Twenty mcg PO every 12 hr is above the recommended dosage range for digoxin. 4. Twenty- ve mcg PO every 12 hr is above the recommended dosage range for digoxin. TEST-TAKING TIP: Ratio and proportion method: The baby in the scenario weighs 7 lb 8 oz, or 71⁄2 lb (there are 16 oz per pound).
The nurse is implementing the plan of care for a child with acute rheumatic fever. Which of the following would the nurse expect to administer if ordered? Select all that apply. A. Corticosteroids B. Digoxin C. Intravenous immunoglobulin D. Penicillin E. Nonsteroidal anti-inflammatory drugs
A, D, E A full 10-day course of penicillin or equivalent is used. Corticosteroids are used as part of the treatment for acute rheumatic fever. Nonsteroidal anti-inflammatory drugs are used as part of the treatment for acute rheumatic fever. Digoxin is used to treat heart failure, atrial fibrillation, atrial flutter, and supraventricular tachycardia. Intravenous immunoglobulin is used to treat Kawasaki disease.
A nursing instructor is preparing for a class about the structural and functional differences in the cardiovascular system of infants and children as compared to adults. Which of the following would the instructor include in the class discussion? A. Left ventricular function predominates immediately after birth. B. The heart's apex is higher in the chest in children younger than the age of 7 years. C. Blood pressure is initially high at birth but gradually decreases to adult levels. D. The heart is about four times the birth size between the ages of 6 and 12 years.
B In infants and children younger than age 7 years, the heart lies more horizontally, resulting in the apex lying higher in the chest
The nurse is providing child and family education prior to discharge following a cardiac catheterization. The nurse is teaching about signs and symptoms of complications. Which statement by the mother indicates a need for further teaching? A. "We need to watch for changes in skin color or difficulty breathing." B. "The feeling of the heart skipping a beat is common." C. "We need to avoid a tub bath for the next 3 days." D. "Strenuous activity should be limited for the next 3 days."
B Reports of heart "fluttering" or "skipping a beat" should be reported to the doctor as this can be a sign of a complication.
The nurse has administered oral penicillin as ordered for prophylaxis of endocarditis. The nurse instructs the parents to immediately report which of the following reactions? A. Stomach upset B. Wheezing C. Abdominal distress D. Nausea with diarrhea
B The nurse must report any hypersensitivity reactions such as wheezing and pruritus, as these could be a sign of anaphylaxis.
The nurse is reviewing the laboratory test results of several children who have come to the clinic for evaluation. Which child would the nurse identify as having the least risk for hyperlipidemia? A. Child B with a total cholesterol level of 175 mg/dL and LDL of 105 mg/dL B. Child A with a total cholesterol of 150 mg/dL and low-density lipoprotein (LDL) of 80 mg/dL C. Child C with a total cholesterol level of 190 mg/dL and LDL of 125 mg/dL. D. Child D with a total cholesterol level of 220 mg/dL and LDL of 138 mg/dL.
B Total cholesterol levels below 170 mg/dL and LDL levels less than 100 mg/dL are considered within the acceptable range
A newborn baby is receiving digoxin (Lanoxin) and furosemide (Lasix) for congestive heart failure. Which of the following actions would be appropriate for the nurse to perform? 1. Hold digoxin if the apical heart rate is 170 bpm. 2. Hold digoxin for a digoxin level of 1 ng/mL. 3. Hold both the digoxin and furosemide for a weight increase of 5% in one day. 4. Hold both the digoxin and the furosemide for a potassium 3.2 mEq/L.
ANSWER: 4 Rationale: 1. Tachycardia is one sign of CHF and is an indication for the administration of digoxin. 2. A dig level of 1 ng/mL is within the therapeutic range of the medication (0.8 to 2 ng/mL). 3. Fluid retention is a sign of CHF and is an indication for the administration of both digoxin and furosemide. 4. A serum potassium level of 3.2 mEq/L is well below the normal for a newborn of 3.7 to 5.9 mEq/L. e nurse should hold both medications and notify the health-care provider who ordered them. TEST-TAKING TIP: Hypokalemia, or a serum potassium level that is lower than normal, places the body at high risk for cardiac arrhythmias. In addition, when digoxin is taken, the potential for the cardiac arrhythmias increases. Furosemide increases the excretion of potassium. It is essential, therefore, that the nurse not administer the medications until the hypokalemia has been reported and action has been taken to return the electrolyte level to normal.
A nurse is taking the history of a 4-year-old boy who will undergo a cardiac catheterization. Which of the following statements by his mother may necessitate rescheduling of the procedure? A. "He is allergic to iodine and shellfish." B. "He seems listless and slightly warm." C. "He is not taking any medication." D. "He is very scared and nervous about the procedure."
B Fever and other signs and symptoms of infection may necessitate rescheduling the procedure
A 7-year-old child has been diagnosed with rheumatic fever. Which of the following physical ndings would the nurse expect to assess? 1. Vesicular rash over the face and chest 2. Warm and swollen knees and elbows 3. Palpable mass in the upper right quadrant of the abdomen 4. Yellow pigmentation of the sclerae of the eyes
NSWER: 2 Rationale: 1. Erythema marginatum is one of the major manifestations of RF; however, it is not a vesicular rash. It is a well-demarcated macular rash that is seen on the torso and inner surfaces of the extremities. 2. Polyarthritis, one of the major manifestations of RF, is manifested by warm, swollen, and painful joints. 3. Abdominal masses are not associated with RF. 4. Yellow pigmentation of the sclerae is not associated with RF. TEST-TAKING TIP: When a child presents with a specific diagnosis, the nurse, unless it is contraindicated, should assess for the common signs and symptoms of the disease. In the case of RF, for example, the nurse should assess for the manifestations as listed in the Jones criteria.
