TEST 3 252
What statement by the registered nurse (RN) is the best response to the mother of a 10 day newborn asking for an explanation of her son's diagnosis of coarctation of the aorta. "This heart defect causes a twisting of the aorta (the major artery in the body) that causes a difference in blood flow to the upper and lower parts of your son's body." "This heart defect causes a narrowing of the vena cava (major vein in the body) that causes a difference in blood flow to the upper and lower parts of your son's body." "This heart defect causes a shortening of the aorta (the major artery in the body) that causes a difference in blood flow to the upper and lower parts of your son's body." "This heart defect causes a narrowing of the aorta (the major artery in the body) that causes a difference in blood flow to the upper and lower parts of your son's body."
"This heart defect causes a narrowing of the aorta (the major artery in the body) that causes a difference in blood flow to the upper and lower parts of your son's body." rationale: Coarctation of the aorta is a localized narrowing of the aortic lumen. Coarctation of the aorta usually occurs at the proximal thoracic aorta just beyond the left subclavian artery and just across from the opening of the ductus arteriosus. The effect of a narrowing within the aorta is increased pressure proximal to the defect and decreased pressure distal to it. Coarctation rarely involves the abdominal aorta. Thus, in utero and before the patent ductus arteriosus (PDA) closes, much of the cardiac output bypasses the coarctation via the PDA. Coarctation may occur alone or with various other congenital anomalies.
If warfarin is contraindicated as a treatment for stroke, which medication is the best option? Dipyridamole Aspirin Clopidogrel Ticlodipine
Aspirin Explanation: If warfarin is contraindicated, aspirin is the best option, although other medications may be used if both are contraindicated.
The nurse is teaching a client on toxicity while taking phenytoin sodium. The nurse determines the teaching is successful after the client describes which of these should be reported to the health care provider (HCP)? Select all that apply. Hyperactivity Diplopia Bruising Slurred speech Hearing impairment
Diplopia Slurred Speech rationale: Phenytoin is an anti-epileptic or anticonvulsant medication used to prevent and treat certain types of seizures. It works by decreasing the impulse activity in the brain that can cause seizures. Phenytoin is one of a few medications with therapeutic blood levels needed to be effective and prevent toxicity side effects. Blood levels should be monitored and maintained at 10-20 mcg/mL to prevent toxicity symptoms. Toxic side effects of phenytoin therapy include CNS effects such as visual disturbances, nystagmus, slurring speech, lethargy, coma, or death.
The nurse is assessing a client who has been on phenytoin for 10 years. Which characteristic finding is observed in clients with a long-term history of taking phenytoin sodium? Excessive growth of gum tissue. Enlarged tonsils. Dry scaly skin. Mania
Excessive growth of gum tissue. rationale: Phenytoin is an anti-epileptic or anticonvulsant medication used to prevent and treat certain types of seizures. It works by decreasing the impulse activity in the brain that can cause seizures. Long-term use of phenytoin can cause gingival hyperplasia (excessive growth of gum tissue). The client should be instructed to have good oral hygiene and to follow-up at least every 6 months with the dentist to have this potential complication of phenytoin monitored. Self-monitoring should be taught to the client and any change of the gums reported to the health care professional.
An emergency department nurse is interviewing a client who is presenting with signs of an ischemic stroke that began 2 hours ago. The client reports a history of a cholecystectomy 6 weeks ago and is taking digoxin, warfarin, and labetalol. What factor poses a threat to the client for thrombolytic therapy? International normalized ratio greater than 2 Two hour time period of the stroke Taking digoxin Surgery 6 weeks ago
International normalized ratio greater than 2 Explanation: The client is at risk for further bleeding if the international normalized ratio is greater than 2. Thrombolytic therapy must be initiated within 3 hours in clients with ischemic stroke. The client is not eligible for thrombolytic therapy if she has had surgery within 14 days. Digoxin and labetalol do not prohibit thrombolytic therapy.
Which is a contraindication for the administration of tissue plasminogen activator (t-PA)? Intracranial hemorrhage Ischemic stroke Age 18 years or older Systolic blood pressure less than or equal to 185 mm Hg
Intracranial hemorrhage Explanation: Intracranial hemorrhage, neoplasm, and aneurysm are contraindications for t-PA. Clinical diagnosis of ischemic stroke, age 18 years or older, and a systolic blood pressure less than or equal to 185 mm Hg are eligibility criteria.
The nurse is receiving a new admission from the emergency department with seizures. Which of the following actions will the nurse perform to institute seizure precautions? Select all that apply. Provide a visible airway at the bedside or connected to the headwall. Place a padded tongue blade at the bedside or connected to the headwall. Ensure the bed is in a high position with a bedside sign to maintain position. Ensure the bed is in a low position with a bedside sign to maintain position. Place pads around the inside of the hospital bed for protection.
Provide a visible airway at the bedside or connected to the headwall. Ensure the bed is in a low position with a bedside sign to maintain position. Place pads around the inside of the hospital bed for protection. rationale: Seizures are uncontrolled, sudden electrical impulses in the brain which make individuals do various things, depending on the cause. Client symptoms include changes in behavior, uncontrollable movements, and changes in level of consciousness. Seizure precautions include having airways available, and oxygen and suction equipment and supplies at bedside. Additionally, side rails may be padded and the bed is kept in the low position. Using a tongue blade whether padded or not may injure the client during a seizure and are not recommended. Two of the major nursing priorities when a client has a seizure is airway management (first) and safety (second).
The nurse is performing an assessment on a client with an intracranial hematoma. Which assessment finding is most important? Increased muscular pain, especially during sleep. Cogwheel rigidity. Tingling to extremities and inability to ambulate. Hamstring and spinal pain leading to resistance when the hip and knee is flexed then extended.
Hamstring and spinal pain leading to resistance when the hip and knee is flexed then extended. rationale: Hamstring pain and resistance when the hip and knee are flexed then extended is an example of positive Kernig's sign and may occur with intracranial hematomas. In Kernig's, the client is supine and when the examiner passively straightens the leg at the knee (after flexion to 90 degrees), the client may experience pain along the spine which prevents or limits passive extension of the knee. It is important to note that pain alone is not a positive Kernig's sign, but pain leading to resistance or contracture is a positive sign. The pain associated with intracranial bleeding is not isolated to nighttime only. If present, it may indicate increased pressure and may be severe and persistent.
Which term will the nurse use when referring to blindness in the right or left half of the visual field in both eyes? Scotoma Diplopia Nystagmus Homonymous hemianopsia
Homonymous hemianopsia Explanation: Homonymous hemianopsia occurs with occipital lobe tumors. Scotoma refers to a defect in vision in a specific area in one or both eyes. Diplopia refers to double vision or the awareness of two images of the same object occurring in one or both eyes. Nystagmus refers to rhythmic, involuntary movements or oscillations of the eyes.
The nurse caring for a client with a brain injury administered mannitol for increased intracranial pressure. Which is the most important for the nurse to monitor following administration of mannitol? Intake and output. Pupillary response. Changes in pulse pressure Respiratory rate.
Intake and output. rationale: Mannitol is an osmotic diuretic used to force urine output to decrease intracranial pressure in clients with cerebral edema. Mannitol is also used to increase urine production in clients with acute renal failure and to decrease edema and excessive fluid in the eyes. The osmotic action pulls water from extracellular fluid of the brain. Since mannitol is a diuretic, the excessive fluid in the brain is eliminated through the kidneys as urinary output. While on mannitol, the urinary output is generally more than the input. The nurse should monitor the client for intake and output. The goal with this therapy is reduction of cerebral edema to restore neurologic function to the client.
A client with chronic obstructive pulmonary disease (COPD) is intubated and placed on continuous mechanical ventilation. Which equipment is most important for the nurse to keep at this client's bedside? Tracheostomy cleaning kit Water-seal chest drainage set-up Manual resuscitation bag Oxygen analyzer
Manual resuscitation bag Explanation: The client with COPD depends on mechanical ventilation for adequate tissue oxygenation. The nurse must keep a manual resuscitation bag at the bedside to ventilate and oxygenate the client in case the mechanical ventilator malfunctions. Because the client doesn't have chest tubes or a tracheostomy, keeping a water-seal chest drainage set-up or a tracheostomy cleaning kit at the bedside isn't necessary. Although the nurse may keep an oxygen analyzer (pulse oximeter) on hand to evaluate the effectiveness of ventilation, this equipment is less important than the manual resuscitation bag.
The nurse is caring for a patient having a hemorrhagic stroke. What position in the bed will the nurse maintain this patient? High-Fowler's Prone Supine Semi-Fowler's
Semi-Fowler's Explanation: The head of the bed is elevated 15 to 30 degrees (semi-Fowler's position) to promote venous drainage and decrease intracranial pressure.
After lobectomy for lung cancer, a client receives a chest tube connected to a disposable chest drainage system. The nurse observes that the drainage system is functioning correctly when she notes tidal movements or fluctuations in which compartment of the system as the client breathes? Water-seal chamber Air-leak chamber Collection chamber Suction control chamber
Water-seal chamber Explanation: Fluctuations in the water-seal compartment are called tidal movements and indicate normal function of the system as the pressure in the tubing changes with the client's respirations. The air-leak meter — not chamber — detects air leaking from the pleural space. The collection chamber connects the chest tube from the client to the system. Drainage from the tube drains into and collects in a series of calibrated columns in this chamber. The suction control chamber provides the suction, which can be controlled to provide negative pressure to the chest.
the emergency dept. nurse is assessing a client who just sustained a blunt injury to the chest wall. which finding indicates pneumothorax? a low respiratory rate diminished breath sounds barrel chest sucking sound at site of injury
diminished breath sounds rationale: symptoms of closed pneumothorax are shortness of breath and chest pain. larger pneumothorax may cause tachypnea, cyanosis, diminished breath sounds and subcutaneous emphysema. hyper-resonance may occur on the affected side. sucking sound occurs with open pneumothorax
A client with pneumonia develops respiratory failure and has a partial pressure of arterial oxygen of 55 mm Hg. The client is placed on mechanical ventilation with a fraction of inspired oxygen (FIO2) of 0.9. What setting would be the best maximum FIO2 setting? 0.21 0.35 0.5 0.7
0.5 Explanation: An FIO2 greater than 0.5 for as little as 16 to 24 hours can be toxic and can lead to decreased gas diffusion and surfactant activity. Clients with respiratory disorders are given oxygen therapy only to increase the partial pressure of oxygen (PaO2) back to the patient's normal baseline, which may vary from 60 to 95 mm Hg. In terms of the oxyhemoglobin dissociation curve, arterial hemoglobin at these levels is 80% to 98% saturated with oxygen; higher FiO2 flow values add no further significant amounts of oxygen to the red blood cells or plasma. Instead of helping, increased amounts of oxygen may produce toxic effects on the lungs and central nervous system or may depress ventilation. The ideal oxygen source is room air FIO2 0.21.
A patient is admitted via ambulance to the emergency room of a stroke center at 1:30 p.m. with symptoms that the patient said began at 1:00 p.m. Within 1 hour, an ischemic stroke had been confirmed and the doctor ordered tPA. The nurse knows to give this drug no later than what time? 2:00 p.m. 3:00 p.m. 4:00 p.m. 7:00 p.m.
4:00 p.m. Explanation: Tissue plasminogen activator (tPA) must be given within 3 hours after symptom onset. Therefore, since symptom onset was 1:00 pm, the window of opportunity ends at 4:00 pm.
A nurse who provides care at a community clinic is in contact with a diverse group of patients. Which of the following individuals most clearly displays risk factors for stroke? A man who is receiving oral antibiotics for the treatment of a chlamydial infection A woman who has osteoporosis, a history of fractures, and a family history of stroke An obese woman with a history of atrial fibrillation and type 2 diabetes A 70-year-old man who has benign prostatic hyperplasia and early stage Alzheimer's disease
An obese woman with a history of atrial fibrillation and type 2 diabetes Explanation: Obesity, atrial fibrillation, and type 2 diabetes are all highly significant risk factors for stroke. None of the other listed individuals displays multiple risk factors for stroke.
A client with chronic obstructive pulmonary disease (COPD) admitted for suspected acute respiratory failure has just arrived at their room on the med-surg floor. The nurse has a student nurse helping her get the client settled in. Which intervention by the student nurse requires correction? Raising the bed for the client to high Fowler's position. Assembling the oxygen with 4L bi-nasal cannula onto the client. Making sure intubation supplies are at the bedside. Prepare the client for hemodynamic monitoring.
Assembling the oxygen with 4L bi-nasal cannula onto the client. rationale: The client with acute respiratory failure will require supported measures for proper ventilation. These include proper positioning, oxygen use, BiPAP, mechanical ventilation, and hemodynamic monitoring. The COPD client can become hypercapnic which leads to what is referred to as "hypoxic drive". This is a theory that the brain no longer responds to carbon dioxide retention and the client loses the ability to maintain proper oxygen levels. For this reason, a Venturi mask is preferred over a regular oxygen mask or bi-nasal cannula when administering oxygen. The Venturi mask mixes room air with oxygen and creates a high-flow oxygen delivery system. The oxygen is controlled at the appropriate concentration for the client without knocking out the client's respiratory drive.
An emergency department nurse overhears on dispatch that over 20 children from a local school are being brought in for flu-like symptoms while on their way to a field trip on a school bus. Symptoms include headache, dizziness, nausea, vomiting, and chest pain. The nurse suspects which most probable illness? An outbreak of influenza. Rocky mountain spotted fever. Carbon monoxide poisoning. Food poisoning.
Carbon Monoxide Poisoning This answer is correct because these are symptoms of carbon monoxide poisoning. The children riding the bus have most likely been exposed to carbon monoxide. The question mentions the children were "on their way" to a field trip by bus. Carbon monoxide poisoning can happen in a short period of time.
A client is on a positive-pressure ventilator with a synchronized intermittent mandatory ventilation (SIMV) setting. The ventilator is set for 8 breaths per minute. The client is taking 6 breaths per minute independently. The nurse Consults with the physician about removing the client from the ventilator Changes the setting on the ventilator to increase breaths to 14 per minute Continues assessing the client's respiratory status frequently Contacts the respiratory therapy department to report the ventilator is malfunctioning
Continues assessing the client's respiratory status frequently Explanation: The SIMV setting on a ventilator allows the client to breathe spontaneously with no assistance from the ventilator for those extra breaths. Data in the stem suggest that the ventilator is working correctly. The nurse would continue making frequent respiratory assessments of the client. There are not sufficient data to suggest the client could be removed from the ventilator. There is no reason to increase the ventilator's setting to 14 breaths per minute or to contact respiratory therapy to report the machine is not working properly.
A nurse is planning care for a client who experienced a stroke in the right hemisphere of his brain. What should the nurse do? Anticipate the client will exhibit some degree of expressive or receptive aphasia. Place the wheelchair on the client's left side when transferring him into a wheelchair. Provide close supervision because of the client's impulsiveness and poor judgment. Support the right arm with a sling or pillow to prevent subluxation.
Provide close supervision because of the client's impulsiveness and poor judgment. Explanation: The primary symptoms of a client who experiences a right-sided stroke are left-sided weakness, impulsiveness, and poor judgment. Aphasia is more commonly present when the dominant or left hemisphere is damaged. When a client has one-sided weakness, the nurse should place the wheelchair on the client's unaffected side. Because a right-sided stroke causes left-sided paralysis, the right side of the body should remain unaffected.
A patient is brought to the emergency department with a possible stroke. What initial diagnostic test for a stroke, usually performed in the emergency department, would the nurse prepare the patient for? 12-lead electrocardiogram Carotid ultrasound study Noncontrast computed tomogram Transcranial Doppler flow study
Noncontrast computed tomogram Explanation: The initial diagnostic test for a stroke is usually a noncontrast computed tomography (CT) scan. This should be performed within 25 minutes or less from the time the patient presents to the emergency department (ED) to determine if the event is ischemic or hemorrhagic (the category of stroke determines treatment).
A client is being discharged with a new prescription of phenytoin. Which instruction by the nurse is most important to include? If stopped abruptly, status epilepticus may occur. Sulfonamides like sulfamethoxazole trimethoprim will decrease phenytoin levels in the blood. Take the medication with antacids to reduce gastric upset. Dilantin will not affect contraceptive effectiveness.
If stopped abruptly, status epilepticus may occur. rationale: This answer is correct because it is important to instruct a client with a new prescription of phenytoin not to suddenly stop taking phenytoin, as doing so may present a risk for return of life-threatening seizure activity. Phenytoin is an anti-epileptic or anticonvulsant medication used to prevent and treat certain types of seizures. It works by decreasing the impulse activity in the brain that can cause seizures. The nurse should teach a client newly prescribed phenytoin to never abruptly stop taking the medication. Abrupt withdrawal of this medication is dangerous and can cause life-threatening seizure activity. The client should always plan ahead to have prescriptions filled, have extra medications available, and be systematic and consistent with taking phenytoin. all of the other answers have the opposite effects.
The nurse is assessing a female 30-year-old client with a history of seizures, which are controlled with the medication clonazepam. What questions are important for the nurse to ask? Select all that apply. Is the client pregnant? Does the client drink alcohol? When was the last seizure? Does the client drink sugary carbonated beverages? How much clonazepam does the client take daily?
Is the client pregnant? Does the client drink alcohol? When was the last seizure? How much clonazepam does the client take daily? rationale: Clonazepam is in the benzodiazepine class of medication used as an anticonvulsant or antiepileptic. It is used to control and prevent seizures by decreasing stimulation to the nerves in the brain that cause seizures. The nurse should assess the client prior to administration to determine education needs, safety, and risk factors associated with use of this medication. The nurse should determine if the client is pregnant because clonazepam is in the pregnancy D category. Clonazepam crosses the placental barrier and can cause an increased incidence of birth defects, including cleft palate and cleft lip if taken in the first trimester. Ingestion of alcohol while taking clonazepam will increase the central nervous system effects, including dangerous respiratory and CNS depression. Also, taking clonazepam while drinking alcohol can greatly increase the risk of addiction. The nurse should educate the client to not combine alcohol and clonazepam. Determination of the type and most recent seizure is important. This assessment will help understand the effectiveness of clonazepam treatment and if there is a need to make changes.
For a client who has a chest tube connected to a closed water-seal drainage system, the nurse should include which action in the care plan? Measuring and documenting the drainage in the collection chamber Maintaining continuous bubbling in the water-seal chamber Keeping the collection chamber at chest level Stripping the chest tube every hour
Measuring and documenting the drainage in the collection chamber Explanation: The nurse should regularly measure and document the amount of chest tube drainage to detect abnormal drainage patterns, such as may occur with a hemorrhage (if excessive) or a blockage (if decreased). Continuous bubbling in the water-seal chamber indicates a leak in the closed chest drainage system, which must be corrected. The nurse should keep the collection chamber below chest level to allow fluids to drain into it. The nurse shouldn't strip chest tubes because doing so may traumatize the tissue or dislodge the tube.
During the ictal phase, which of these are important in the assessment of the client? Vital signs including oximeter readings. Movement of eyes, head, and muscle rigidity. Determining what type of aura occurred. Determining what the client was doing just prior to the seizure.
Movement of eyes, head, and muscle rigidity. rationale: During a seizure, the ictal stage is the most intense part of the seizure with symptoms including eye movement, head movement, falling, shaking of the whole body, loss of bowel or bladder control, grunting, body stiffness (muscle rigidity), and tongue smacking. Data gathered during the ictal stage of a seizure is important because it can guide the diagnostician in the direction of brain involvement, which can lead to treatment options and differential diagnoses. Vital signs are always important; however, not possible during this phase. Aura is the first part of the seizure before the client loses consciousness. It is described like a warning signal. Determining what type of aura the client experienced will not be practicable during ictus, since the client will most likely be unable to communicate. Discovering the client's activity prior to the seizure will likely be possible after the recovery phase of the seizure when the client is back to their baseline and not during the seizure.
The nurse is caring for a client in the intensive care unit who has been on a ventilator set on 80% FiO2 for three days. The nurse will observe the client for risk of having which condition as a result of prolonged ventilator settings with 80% FiO2? Pulmonary fibrosis. Pleural effusion. Pneumonia. Legionnaires Disease.
Pulmonary fibrosis. rationale: Oxygen toxicity is a condition that results from the harmful effects of excessive oxygen at increased partial pressures. This client is at high risk for oxygen toxicity due to delivery of 80% FiO2 for three days. Oxygen toxicity can lead to the deposition of excess collagen and thickening of the interstitial pulmonary space causing pulmonary fibrosis. The nurse should monitor for signs of oxygen toxicity, including excess coughing in all clients receiving high amounts of oxygen for prolonged periods.
While providing information to a community group, the nurse tells them the primary initial symptoms of a hemorrhagic stroke are: Weakness on one side of the body and difficulty with speech Severe headache and early change in level of consciousness Foot drop and external hip rotation Confusion or change in mental status
Severe headache and early change in level of consciousness Explanation: The main presenting symptoms for ischemic stroke are numbness or weakness of the face, arm, or leg, especially on one side of the body, confusion or change in mental status, and trouble speaking or understanding speech. Severe headache, vomiting, early change in level of consciousness, and seizures are early signs of a hemorrhagic stroke. Foot drop and external hip rotation can occur if a stroke victim is not turned or positioned correctly.
The nurse is assessing a client following a thoracentesis and immediately reports which finding to the health care provider? Subcutaneous emphysema around the site. Serous drainage oozing from site. Increased temperature to 100.4°/ 38 C. Diminished breath sounds on the affected side.
Subcutaneous emphysema around the site. rationale: Subcutaneous emphysema, or crepitus, produces a "rice crispies" feeling upon palpation. This is caused by the leakage of air into the subcutaneous space. The finding of subcutaneous emphysema around the insertion site post-thoracentesis could indicate that the lung was inadvertently punctured during the procedure and should be immediately reported to the health care provider (HCP). A tension pneumothorax could result if this is not immediately recognized and treated.
The nurse is assisting a physician with an endotracheal intubation for a client in respiratory failure. It is most important for the nurse to assess for: Symmetry of the client's chest expansion Tracheal cuff pressure set at 30 mm Hg Cool air humidified through the tube A scheduled time for deflation of the tracheal cuff
Symmetry of the client's chest expansion Explanation: Immediately after intubation, the nurse should check for symmetry of chest expansion. This is one finding that indicates successful endotracheal placement. The tracheal cuff pressure is set between 15 and 20 mm Hg. Routine deflation of the tracheal cuff is not recommended, because the client could then aspirate secretions during the period of deflation. Warm, high, humidified air is administered through the endotracheal tube.
The nurse is caring for a client who has a chest tube following cardiac surgery and observes a dramatic decrease in chest tube drainage from the first hour to the second hour after surgery. Evaluation of the chest tube system indicates which problem? The lungs are not at risk and are fully inflated. The client is recovering without further drainage. There may be tube obstruction due to a drainage clot. Tension pneumothorax is pending, so call the health care provider immediately.
There may be tube obstruction due to a drainage clot. rationale: This answer is correct because the first hours following cardiac surgery may have chest tube drainage as high as 100 mL/hr but should begin slowing down after a few hours, not just in the second hour. Therefore, there must be an obstruction such as a clot or kink in the tubing.
Which is the most reliable and accurate method for delivering precise concentrations of oxygen through noninvasive means? Nasal cannula Venturi mask T-piece Partial-rebreathing mask
Venturi mask Explanation: The Venturi mask is the most reliable and accurate method for delivering a precise concentration of oxygen through noninvasive means. The mask is constructed in a way that allows a constant flow of room air blended with a fixed flow of oxygen. Nasal cannula, T-piece, and partial-rebreathing masks are not the most reliable and accurate methods of oxygen administration.
Which type of ventilator has a preset volume of air to be delivered with each inspiration? Negative pressure Volume cycled Time cycled Pressure cycled
Volume cycled Explanation: With volume-cycled ventilation, the volume of air to be delivered with each inspiration is preset. Negative-pressure ventilators exert a negative pressure on the external chest. Time-cycled ventilators terminate or control inspiration after a preset time. When the pressure-cycled ventilator cycles on, it delivers a flow of air (inspiration) until it reaches a preset pressure, and then cycles off, and expiration occurs passively.
While assessing a 3 year old diagnosed with a congenital heart defect the registered nurse (RN) is aware that which presentation will support the presence of hypoxemia? Select all that apply. extreme alertness to sounds and environmental changes strong, bounding pulses in the upper and lower extremities increased warmth of the skin with a deep pink hue noted abnormally large number of red blood cells in the circulating system thickening and flattening of the tips of the fingers and toes
abnormally large number of red blood cells in the circulating system thickening and flattening of the tips of the fingers and toes rationale: Over time, two physiologic changes occur in the body in response to chronic hypoxemia: polycythemia and clubbing. Persistent hypoxemia stimulates erythropoiesis, which results in polycythemia, an increased number of red blood cells. Polycythemia increases the viscosity of the blood, and platelets and other coagulation factors tend to be crowded out. Clubbing, a thickening and flattening of the tips of the fingers and toes, is thought to occur because of chronic hypoxemia and polycythemia. The infant experiencing severe hypoxemia results in tissue hypoxia and is manifested by pale dusky skin with increased cyanosis, diminished pulses, lethargy, cool to touch skin, and signs of respiratory distress.
While providing care for a 1 month old newborn, which clinical presentation observed by the registered nurse (RN) supports the possible diagnosis of tetralogy of fallot? Select all that apply. abdominal distention steady weight gain cyanosis with crying oxygen saturation of 80% dyspnea with feeding
cyanosis with crying oxygen saturation of 80% dyspnea with feeding rationale: With a diagnosis of tetralogy of fallot (TOF), some neonates may be acutely cyanotic at birth, others have mild cyanosis. This mild cyanosis will progress over the first year of life as the pulmonic stenosis worsens. Neonates with severe right ventricular outflow obstruction have severe cyanosis and dyspnea during feeding, leading to poor weight gain. Neonates with mild obstruction may not have cyanosis at rest. With TOF there is a characteristic systolic ejection murmur heard in the mid and upper sternal border.
the nurse is assessing a client with multiple trauma who is at risk for developing ARDS. Which is the earliest sign of ARDS? bilateral wheezing inspiratory crackles intercostal retractions
increased respiratory rate rationale: the earliest detectable sign of of ARDS is an increased respiratory rate which can begin from 1-96 hrs after the initial insult to the body. This is followed by increasing dyspnea, air hunger, retraction of accessory muscles and cyanosis. breath sounds may be clear or consist of inspiratory crackles or diffuse coarse crackles.
a client with a chest injury has suffered flail chest. Which is the most distinctive sign of flail chest? cyanosis hypotension paradoxical chest movement dyspnea, especially on exhalation
paradoxical chest movement rationale: flail chest results from multiple rib fractures. this results in a floating section of ribs. because this section is unattached to to the rest of the rib cage, this segment results in paradoxical chest movement. this means that the force of inspiration pulls the fractured segment inward while the rest of the chest expands. similarly during exhalation, the segment balloons outward while the rest of the chest moves inward.
While caring for a 5 week old infant diagnosed with a ventricular septal defect, the registered nurse (RN) recognizes which clinical manifestation supports this diagnosis? Select all that apply. continuous crying poor weight gain fatigue after feeding grunting during feeding loud systolic murmur
poor weight gain fatigue after feeding grunting during feeding loud systolic murmur rationale: Symptoms of heart failure (eg, respiratory distress, poor weight gain, grunting during feeding, and fatigue after feeding) appear at age 4 to 6 weeks when pulmonary vascular resistance falls. loud systolic murmur is a clinical manifestation expected in the newborn diagnosed with ventricular septal defect. A ventricular septal defect (VSD) is an abnormal opening between the right and left ventricles. A loud, harsh, holosystolic murmur at the lower left sternal border is common.
