NUR 102 Exam 5_Perfusion

The nurse provides home care instructions to the parents of a child with HF regarding the procedure for administration of Digoxin. Which statement made by the parents indicates A FURTHER NEED FOR TEACHING? A. "I will not mix medication with food" B. "I will take my childs apical pulse before administering" C. "If more than 1 dose is missed, call HCP" D. "If my child vomits, I will repeat the dose"

D If a child vomits, do NOT repeat the dose. Everything else is correct.

The nurse is monitoring an infant with HF. Which sign alerts the nurse to suspect fluid accumulation and the need to call HCP? A. Bradypnea B. Diaphoresis C. Decreased Blood pressure D. Weight gain of 1 lbs. in 1 day.

D bradypnea and decreased blood pressure are a result of fluid accumulation and Diaphoresis is not associated with HF.

The nurse should explain to the parents that their child is recieving Furosemide (Lasix) for severe CHF because it is a/an: A. diuretic B. alpha blocker C. form of digitalis D. ACE inhibitor

A Lasix is a loop diuretic, which means it is metabolized through the loop of Henle in the kidneys. It is used to get rid of extra salt in the body to keep from fluid overload.

What should the nurse recognize as an early clinical sign of compensated shock in a child? A. confusion B. sleepiness C. hypotension D. apprehension

D confusion is uncompesated shock. Sleepiness has nothing to do with shock. Hypotension is irreversable shock.

The nurse is caring for an infant with a diagnosis of Tetralogy of Fallot. The infant suddenly becomes cyanotic, and the nurse recognizes that the infant is experiencing a hypercyanotic spell. The nurse IMMEDIATELY places infant in what position? A. prone position B. knee-chest position C. High Fowlers position D. reverse Trendelenburg's position.

B Knee-chest will improve oxygen saturation, the other positions hinder it.

The nurse has provided home care instructions to the parents of a child who is being discharged after cardiac surgery. Which statement made by the parents indicates a NEED FOR FURTHER TEACHING? A. "A balance of rest and exercise is important" B. "I can apply lotion or powder to the incision if it is itchy" C. "Activities in which my child could fall need to be avoided for 2-4 weeks." D. "Large crowds need to be avoided for more than 2 weeks after surgery"

B Lotion and powder is not a good thing to use on an incision because it can set grounds for infection in the incision and irritate the site even more.

Prostaglandin E1 is prescribed for a child with Transposiiton of the Great Arteries. The mother of the child is a registered nurse and asks the nurse why the child needs the medication. What is the MOST APPROPRIATE response the nurse should give? A. Prevents blue (tet) spells B. maintains adequate Cardiac Output C. maintains adequate hormonal levels D. maintains position of Great Arteries

B tet spells occur with Tetralogy of Fallot. All other options are inaccurate

Nursing care of an infant/child with Congestive Heart Failure would include: A. forcing fluids appropriate to age. B. monitor RR during active periods. C. organizing activities to allow uninterrupted sleep. D. giving larger feedings less often to conserve energy.

C The last thing a CHF child needs is stress, so minimizing energy may be vital! No large feedings, as the child cannot tolerate it. In CHF, you would see fluid excess, not deficit. The child/infant needs to be well-rested before feedings.

A child is being discharged following cardiac surgery. Prior to discharge there are instructions given to the mother. Which statement indicates A NEED FOR FURTHER TEACHING? A. "Quiet activities are allowed" B. "The child should play inside for now" C. "No visitors for 1 month" D. "Regular naps will continue as scheduled"

C Visitors are still allowed as long as there is no infection in the person visiting. However, the child should be kept away from large crowds for 1 week at least. The rest of the statements are true.

Congenital Heart Defects have traditionally been divided into acyanotic an cyanotic defects. The nurse should recognize that in clinical practice this system is: A. helpful because it explains hemodynamics B. helpful because cyanotic defects are easily identified. C. problematic because cyanosis is rare D. problematic because acyanosis can turn into cyanosis.

D The reverse is also true. Pink or blue does not narrow down to 1 specific defect, it could be quite a few. Theres still more factors to consider before naming the defect.

Nurses counseling parents regarding the home care of the child with a cardiac defect before corrective surgery should stress the: A. importance of decreased caloric intake to decrease cardiac demands. B. importance of relaxing discipline and limit-setting to prevent crying C. needs to be extremely concerned about cyanosis. D. desire of promoting normalcy within the limits of the child's condition

D child needs increased caloric intake. The child also needs discipline and appropriate limits, but not for the purpose of decreasing crying. Decreasing crying is important, but quality of life and learning how to deal with the defect for a short period of time is far more important than that.

Which is considered a mixed cardiac defect? A. pulmonary stenosis B. atrial septal defect C. patent ductus arteriosus D. Transposition of the Great Arteries

D pulmonary stenosis is an obstructive blood flow, atrial septal defect is increased pulmonary flow, and patent ductus arteriosus is also increased pulmonary flow.

A young child with Tetralogy of Fallot may assume a posturing position as a compensatory mechanism. The position automatically assumed by the child is: A. low fowlers position B. prone position C. supine position D. squatting

D Low fowlers will help gas exchange, but does not help with heart compensation. Supine and prone do not benefit the child (they may make things worse).

The nurse is preparing to administer Digoxin to an infant with HF. Before administering the medication, the nurse double-checks the dose and counts the apical rate of 80 beats/min. Based on this finding, what is the nurses MOST APPROPRIATE action? A. Withhold the medication B. Administer the medication C. Check the Blood Pressure and administer the medication D. Check Respiratory Rate and administer the medication.

A Apical pulse is lower than the normal range. Normal range is 90-130 beats/min for an infant.

The nurse is closely monitoring the intake and output of the infant with HF who is recieving diuretic therapy. The nurse should use which most appropriate method to assess the urine output? A. weigh the diapers B. inserting a urinary catheter C. comparing intake with output D. measuring amount of water added to the formula

A Comparing intake with output is not the most accurate. Adding what to formula is irrelevant to output. Urinary catheters are accurate, but sets grounds for infection (and it hurts)

A nurse is preparing to give Digoxin to a 9-month old infant. He/she checks dosage and draws up 4 ml. The MOST appropriate nursing action is to: A. not give dose; suspect dosage error B. mix dose in juice to dilute taste. C. check pulse, administer dose by placing it back/side of mouth. D. check pulse, administer dose by letting infant suck it through a nipple.

A Digoxin is a very small dosage. It is almost never given 1 ml. Furthermore, most facilities require a second RN to check this med.

After a patient returns from cardiac catheterization, the nurse assesses that the pulse distal to catheterization insertion site is weaker. The nurse should: A. elevate affected extremity B. record data in nurse's notes C. notify physician of observation. D. apply warm compress to insertion site.

B Elevation is not necessary, the extremity needs to be straight. The distal pulse will be weak in the first few hours, but should increase in strength as time goes on. If it doesn't, then you would notify physician. Warm compress is not relevent to this. Continue to monitor femoral pulses and temperature, and color of extremity.

A child with a diagnosis of Tetralogy of Fallot exhibits an increased depth and rate of respirations on further assessment, the nurse notes increased hypoxemia. The nurse interprets these findings an in indication to which situation? A. anxiety B. a temper tantrum C. A hypercyanotic episode D. A need for the HCP provider notification

C Anxiety and temper tantrums are not associated with Tetralogy of Fallot. The HCP does not need to be notified unless all other interventions do not work.

Assessment findings of an infant admitted to the hospital reveal a machinery-like murmur on auscultation of the heart and signs of HF. The nurse reviews congenital heart anormalies and identifies the infants condition as which disorder? A. Aortic Stenosis B. Atril Septal Defect C. Patent Ductus Arteriosus D. Ventricular Septal Defect

C Aortic stenosis is narrowing of the aortic valve. Atrial septal defect is when there is a hole in Atrial septum. Same is true for Ventricular septum for Ventricular septal defect.

An important nursing responsibility when a dysrhythmia is suspected is to: A. order an immediate ECG. B. count apical pulse for 1-min intervals 5 times in a row. C. count apical pulse for 1 full minute and compare with radial pulse. D. have someone else take radial pulse while the nurse simeltaneously checks apical rate.

C Apical needs to be compared with radial, but its more accurate if the nurse does it themselves.

A 1 year old infant with a diagnosis of HF is prescribed Digoxin. The nurse takes the apical pulse for 1-minute before administering the medication and obtains a 102 beats/min. What is the nurses BEST action? A. retake the apical pulse B. withhold medication C. Administer the medication D. Notify HCP.

C Apical pulse is normal. Normal range 90-130 beats/min

The nurse is monitoring an infant with Congenital Heart Disease closely for signs of HF. The nurse assesses the infant for what EARLY signs of HF? A. Pallor B. cough C. tachycardia D. slow/shallow breathing

C Coughing and pallor are later signs of HF. Slow/shallow breathing is a sign of respiratory depression.

The nurse is assessing a newborn with HF. Before administering prescribed Digoxin. In reviewing the lab data, the nurse notes that the newborn has a Digoxin blood level of 1.6 ng/mL and an apical rate of 90 beats/min. The mother also tells the nurse that the newborn vomited her formula. Which intervention should the nurse use? A. retake apical pulse B. Administer the medication C. withhold medication for 1 hour. D. withhold the medication and notify HCP.

D 90 beats/min is too low for newborn. Normal levels are 110-160 beats/min. Digoxin levels are also too high. Normal levels are 0.5-0.8 ng/dL

A HCP has prescribed oxygen as needed for an infant with HF. In which situation should the nurse administer oxygen to the infant? A. During sleep. B. changing infants diaper C. mother is holding the infant D. Drawing blood for electrolyte level testing.

D All other choices have little/no chance of making the infant cry. Invasive procedure such as, but not limited to: drawing blood increase the workload of the heart. and increase demands of oxygen.

The nurse is assigned to care for an infant with Tetralogy of Fallot. The mother of the infant calls the nurse to the room because the infant suddenly seems to be having difficulty breathing. The nurse enters and notes the infant is experiencing a hypercyanotic episode. What is the nurses PRIORITY action? A. Notify nurse supervisor B. Contact Respiratory Therapist C. place infant in prone position D. Place infant in knee-chest position

D Nursing supervisors and the Respiratory Therapist contact are things that need to happen, but not the first thing a nurse should do, as the infant is unstable during a hypercyanotic episode. We need to stabilize the infant first. Prone position does not allow to proper perfusion; it makes matters worse.

A doctor suggests that surgery be performed for PDA to prevent: A. pulmonary infection B. Right to left shunts C. decreased workload on Left side of the heart. D. increased pulmonary vascular congestion.

D Primary complication in PDA is shunting from aorta to pulmonary artery, which is from an area of high pressure to low pressure. When PDA is open, it sets grounds for pulmonary congestion.

The school nurse is called to the cafeteria because a child "has eaten something he is allergic to." The child is in severe respiratory distress. FIRST the nurse should: A. determine what the child has eaten. B. administer diphenhydramine (Benadryl) C. move child to nurse's office or hallway. D. have someone call for an ambulance/paramedic rescue squad.

D Since he is in distress, we need to treat him first before we do anything else to open up his airway! Causes can be found once he is more stable. Benadryl does not properly treat anaphylaxis. Do not move the child unless he is in an unsafe space.

The nurse is caring for an infant with a diagnosis of Congenital Heart Disease. Which finding, on physical asssessment, does the nurse attribute to chronic hypoxia? A. tachypnea B. Tachycardia C. Sucking of the fingers D. Clubbing of the fingers.

D Tachypnea and Tachycardia are CHD findings, but they are acute hypoxia. Sucking indicates hunger/irritability, but is not associated with CHD.

The clinic nurse reviews the record of a child just seen by HCP and diagnosed with suspected aortic stenosis. The nurse expect to nore documentation of which clincial manifestation specifically found in this disorder? A. Pallor B. hyperactivity C. Exercise intolerence D. Gastrointestinal disturbances

C Hyperactivity and Gastrointestinal disturbances are not associated with aortic stenosis. Pallor is a sign, but not specific to AS.

The nurse is caring for an infant with Congential Heart Disease. Which, if noted in the infant, should alert the nurse to the EARLY development of Heart Failure? A. paleness B. strong sucking reflex C. Diaphoresis during feeding D. show/shallow breathing

C Paleness is not early sign, but it is an indications of HF. Strong sucking is not associated with HF.

The nurse should instruct a child to remain completely still during which procedure in which high-frequency sound waves are translated into images by a transducer? A. Echocardiography B. Electrocardiography C. Cardiac catheterization D. electrophysiology

A Electrophysiology and Cardiac catheterizations are procedures to treat. Electrocardiography is drawing out depolarization of myocardial cells.

And early sign of CHF that the nurse should recognize is: A. tachypnea B. bradycardia C. inability to sweat. D. increased urine output.

A Tachycardia is a sign of CHF, not bradycardia. Urine output is decreased, not increased Because kidney perfusion is poor.

The nurse is caring for a child with a diagnosis of Right to left heart shunting. On review of the child's record, the nurse should expect to note documentation of which MOST common finding? A. severe bradycardia B. asymptomatic after feeding. C. Bluish discoloration of the skin D. higher than normal body weight.

C severe bradycardia is not a finding, only asymptomatic if there is a Left to Right shunt. The weight would be below normal, not above.

The primary therapy for secondary HTN in children is: A. weight loss B. decreased Na diet. C. increased exercise/fitness D. treatment of underlying cause.

D All therapies listed are ways to treat HTN, but secondary hypertension is caused by primary diagnosis, so treat that first.

The mother of a child being discharged after heart surgery asks the nurse with the child will be able to return to school. Which is the MOST APPROPRIATE response to the mother? A. 1 week B. He may not return to school for the rest of this academic year. C. He may return to school in 1 week, but needs to go half days for the first 2 weeks. D. He may return to school in 3 weeks, but must go half days for the first few days.

D Also no physical education for 2 months after the surgery.