208 test 2 practice
The newborn of a woman diagnosed with gestational diabetes is at risk for respiratory distress because: a. Increased glucose levels inhibit surfactant production b. These babies are macrosomic and always have to be delivered preterm c. The pancreas is making insulin and causes increased surfactant d. The immature red blood cells cannot carry enough oxygenated blood through the newborn
A
The nurse is caring for a child who has been admitted for a sickle cell vaso occlusive crisis. What would the nurse do first to provide adequate pain management? a. Initiate pain assessment with a standardized pain scale b. Use guided imagery and therapeutic touch c. Administer a nonsteroidal anti-inflammatory as ordered d. Administer meperidine (Demerol) as ordered
A
A 3 year old has just been admitted to the hospital for nausea and vomiting. The patient weighs 17.8 kg. What would the patient's daily maintenance fluid requirements are hourly IV fluid rate be?
1390 ml/day, 59 ml/hr
A full term newborn with pathologic hyperbilirubinemia will display which of the following? SATA. a. Increase in bilirubin level by >5 mg/dl in 24 hours b. Serum bilirubin >15 mg/dl c. Visible jaundice for greater than 10 days post delivery d. Clinical jaundice within 24 hours of birth e. Spontaneous resolution of jaundice without treatment
A b c d
A nurse is instituting neutropenic precautions for a child. Which information would the nurse most likely include? SATA. a. Discouraging fresh flowers in the child's room b. Placing a mask on the child when outside the room c. Encouraging an intake of raw fruits and veggies d. Placing the child in a semi-private room e. Avoiding rectal exams, suppositories, and enemas
A b e
A nurse is performing an admission assessment on a client who has been diagnosed with diabetes insipidus. Which findings does the nurse anticipate during the assessment? SATA. a. Extreme urination b. Polyphagia c. BP 90/50 d. Serum osmolality level of 275 mosm/kg e. Urine specific gravity of 1.001
A b e
What would be an appropriate activity for a preschooler with the above defect? A. Swimming classes at the YMCA B. Playing T-ball C. Piano lessons D. Ridings their bike down the block
ANs c
A child is receiving cisplatin (CIS-Platinum) as part of chemotherapy protocol. What would be most important for the nurse to include in the child's plan of care? a. Monitor for muscle weakness or cramping b. Weight daily c. Using prescribed ophthalmic corticosteroid drops d. Monitor for jaw pain
Ans a
In the pre-op assessment of a 4-year old child with an abdominal mass, abdominal distention, and weight loss, which of these common nursing care measures would not be included? A. Palpation of the abdomen for distention and tenderness B. Lung auscultation and cardiac monitoring C. Monitor BUN and creatinine levels D. Strict intake and output monitoring
Ans A
The nurse is working with a child who is immune-suppressed. The parents call the nurse that the child has been exposed to varicella. Which of the following courses of action will the nurse suggest? A. Call the pediatrician and get the child prompt treatment with an intravenous immune globulin with 72hrs of exposure B. Take the child to the emergency room where the doctor will begin IV antibiotics C. Take the child to the doctor's office to be seen by the nurse practitioner or pediatrician D. Isolate the child and get an order for an immunization for varicella if the child has not received the vaccine.
Ans A
Which of the following should the nurse include when teaching the family of an infant newly diagnosed with sickle cell disease? Select all that apply A. Increasing fluids by mouth at home is the first line of treatment when your child has increased pain B. Applying cold compresses to painful areas may help to relieve pain C. Your child will have blood transfusions monthly as routine treatment of sickle cell disease D. Call your doctor if your child ever has a fever You will give your baby Penicillin V daily until age 5 to prevent infections
Ans A d e
A patient at 32 weeks gestation presents to the ER with complaints of headache. She has been preeclamptic since 28 weeks gestation. She has sudden onset edema, 4+ proteinuria. The nurse observes her convulsing. Which of the following actions should the nurse take? A. Assess vital signs every hour B. Maintain patent airway C. Monitor vaginal bleeding every hour D. Administer 8 gram Magnesium Sulfate bolus
Ans B
A pregnant patient has a hemoglobin A1C drawn. The result is 11%. This result would indicate which of the following? A. Controlled diabetes B. Congenital anomalies are highly possible C. Her red blood cells are adequately oxygenating her blood D. Diet and exercise alone will most likely be adequate treatment for this patient.
Ans B
The patient admitted with Hyperglycemia Hyperosmolar Nonketotic Syndrome received 15 units of Novolog subcutaneous on admission by the nurse as ordered. One hour later the patient states "I feel weak and shaky." Which intervention should the nurse implement first? A. Administer eight (8) ounces of orange juice to the patient B. Check the patient's blood sugar C. Administer IV Dextrose 50% one ampule according to the hypoglycemic protocol D. Notify the health care provider immediately
Ans B
The unlicensed assistive personnel (UAP) complains to the nurse that she has filled the water pitcher four (4) times during the shift for a client diagnosed with Diabetes insipidus and the client has asked for the pitcher to be filled again. Which intervention should the nurse implement first? (Med Surg Success--CH 8, #70) A. Instruct the UAP to start measuring the client intake & output B. Assess the client for polyuria & polydipsia C. Check the client BUN and creatinine levels D. Tell the UAP to fill the pitcher with ice cold water
Ans B
A 10 year old comes to the hospital complaining of headaches and nosebleeds. His blood pressure in the right arm is 145/92 and his radial pulse is bounding. On assessment the nurse has difficulty assessing his femoral pulse and his feet are cool. This child most likely has which heart defect? A. Patent ductus arteriosus B. Pulmonic stenosis C. Atrial septal defect D. Coarctation of the aorta
Ans D
A school age child has just been admitted to the unit in a vaso-occlusive crisis. Which of the following would the nurse expect to find in the doctor's order? A. Demerol via PCA pump B. Ice packs to joints C. Platelets two units over 3 hours D. 5 ½ with 20meq KCL at 75ml/hr
Ans D
A toddler is receiving Digoxin for treatment of congenital heart defect. The nurse takes the child's vital signs including an apical pulse before administering the medication. Which of the following vital signs would indicate that the nurse should hold the medication and correct the physician? A. Temp 97.5, HR 95, Resp. 28, BP 104/62 B. Temp 100.4, HR 102, Resp. 42, BP 78/52 C. Temp 101.5, HR 120, Resp. 32, BP 90/54 D. Temp 99.3, HR 87, Resp. 36, BP 82/65
Ans D
The patient diagnosed with Type 2 diabetes arrives at the office for her first antepartum visit at 8 weeks gestation. The nurse draws lab tests on her. The Hemoglobin A1c is 2.3%. this tells the nurse: A. This patient has fair control of her diabetes B. This patient has poor control of her diabetes C. The fetus is at risk for congenital anomalies D. This patient has good control of her diabetes
Ans D
At 28 weeks gestation, a patient is ordered magnesium sulfate for severe pre-eclampsia. The nurse must notify the obstetrician regarding which of the following findings? (Maternal Newborn Success--CH 9, #64) A. Patellar and bicep reflexes of +3 B. Urinary output of 30ml/hour C. Respiratory rate of 16 breath/minute D. Serum magnesium of 9 g/dL
Ans D Rationale: The magnesium sulfate has been ordered because the patient has severe pregnancy-induced hypertension. Patellar and biceps reflexes of +3 are symptoms of the disease. The urinary output must be above 25 mL/hr. The drop in respiratory rate is normal. The therapeutic range of magnesium is 4 to 7 mg/dL.The nurse should report the finding to the physician.
A child hospitalized for chemotherapy for ALL has a platelet count of 75K/UL. Thrombocytopenia precautions have been implemented. Which of the following would be appropriate nursing actions? A. Assess the child's level of consciousness every 4 hours B. Administer Epogen subcutaneous as ordered C. Perform mouth care with the child's favorite motorized toothbrush from home D. Apply pressure to the site of morning lab draw for 5 minutes.
Ans a
A child with sickle cell anemia develops severe chest pain, fever, cough, rapid and shallow respirations and dyspnea. The pulse ox is 85% on room air. The first action by the nurse is to? (Closest I could find is #4 on this quizlet. Wording of the question/answer choices are slightly different, but it's the same rationale I think) A. Notify the physician immediately B. Administer pain medication to relieve symptoms C. Administer 100% oxygen to relieve hypoxia D. Apply warm compress to the chest
Ans a
A patient receiving chemotherapy for ALL is complaining of abdominal distension and bloating. They have not had a bowel movement in 4 days. This could be a side effect of what chemotherapy agent? A. Vincristine B. ARA-C (cytarabinel) C. Adriamycin (doxorubicin) D. L'Asparaginase (asparaginase)
Ans a
The client diagnosed with a lung cancer develops syndrome of inappropriate antidiuretic hormone (SIADH). Which intervention by the nurse is most appropriate? A. Monitor the patient for neck vein distention B. Asses for nausea & vomiting and weigh the patient every other day C. Monitor the patient urine output every 24hours D. Teach the patients in regard to foods high in sodium
Ans a
The newborn of a woman diagnosed with gestational diabetes is at risk for respiratory distress because: Increased glucose levels inhibit surfactant production These babies are macrocosmic and always have to be delivered preterm The pancreas is making insulin and cause increased surfactant The immature red blood cells cannot carry enough oxygenated blood through the newborn.
Ans a
The nurse is preparing to give 0.11 mg of Digoxin to a 9 month old infant. When the nurse checks the dose and draws up 4mL of the drug. The most appropriate nursing action is which of the following? a. Do not give the dose, suspect a dosage error b. Check the HR, ask about feeding tolerance c. ?? d. ??
Ans a
What signs and symptoms could the nurse expect to see in a child with the following heart defect? A. Periods of central cyanosis during increased activity B. Rales auscultated in the bilateral bases of the lungs C. Sudden loss of consciousness during periods of increase activity D. A murmur heart at the left sternal border, 4th intercostal space
Ans a
When the nurse is caring for a child who is receiving Cytoxan or Ifosfamide, the nurse should be aware that the child will also have a physical order for: a. Mesna to treat hemorrhagic cystitis b. Leucovorin to protect against renal failure c. Tylenol to treat pain associated with chemo administration d. Allopurinol to prevent bleeding from the bladder
Ans a
The following facts about RhoGam are true. SATA. a. Blocks production of antibodies that may result in fetal/neonatal hemolytic disease b. RhoGam is 90% effective c. A second dose of RhoGam is indicated within 72 hours of birth if the newborn is Rh+ d. RhoGam is never indicated prior to 28 weeks gestation e. Administered to Rh+ pregnant women at 28 weeks gestation
Ans a b c
A child with ALL is being treated for tumor lysis syndrome. Which of the following actions would the nurse include in the child's care? a. Monitor labs for electrolyte imbalances b. Administer IV fluids containing sodium chloride c. Assess urine output hourly d. Assess cardiovascular status and EKG frequently
Ans a c d
A child with ALL is being treated for tumor lysis syndrome. Which of the following actions would the nurse include in the child's care? Select all that apply. A. Monitor labs for electrolyte imbalances B. Administer IV fluids containing sodium chloride C. Assess urine output hourly D. Assess cardiovascular status and EKG frequently
Ans a c d
A 2-month-old is admitted with a second episode of pneumonia. On admission assessment the nurse auscultates a loud continuous rumbling murmur heart best in the pulmonic area and notifies the physician. The physician suspects a congenital heart defect and orders an ECHO of the heart. Which of the following defects would this child most likely have? A. Ventricular septal defect B. Patent Ductus Arteriosus C. Aortic stenosis D. Pulmonic stenosis
Ans b
A laboring patient complains of suddenly experiencing intense contractions and states, "it feels like something just gave way" as her abdomen becomes tense and painful. She begins to vomit, then the nurse observes hypotonic uterine contractions on the monitor. The nurse would suspect: A. Ectopic pregnancy B. Rupture of the uterus C. Placenta Previa D. Abruptio Placenta
Ans b
A patient with a diagnosis of SIADH is being cared for in the critical care unit. The priority nursing diagnosis for a patient with that condition is what? a. Risk for peripheral neurovascular dysfunction b. Excess fluid volume c. Hypothermia d. Ineffective airway clearance
Ans b
After delivery of a viable infant at full term gestation, a patient is diagnosed with placenta accreta. The nurse knows this patient is at risk for? (Maternal Newborn Success CH. 9, #51) A. Chronic hypertension B. Postpartum hemorrhage C. Eclamptic seizure D. Hyperthermia
Ans b
The nurse is caring for a 6 year old with ALL. The parent states "My child has a low platelet count, and we are being discharged this afternoon. What do I need to do at home?" What statement is most appropriate for the nurse to make? a. "You should feed your child a bland, soft, moist diet for the next week." b. "Your child should avoid contact sports or activities that could cause bleeding." c. "Your child should avoid large groups of people for the next week." d. "You should give your child aspirin instead of acetaminophen for fever or pain."
Ans b
When the nurse is caring for a child who is receiving Cytoxan (cyclophosphamide) or ifosfamide, the nurse should be aware that the child will also have a physician order for? A. Leucovorin to protect against renal failure B. Mesna to treat hemorrhagic cystitis C. Allopurinol to prevent bleeding from the bladder D. Tylenol to treat pain associated with chemotherapy administration
Ans b
Which of the following patients would the nurse recognize as having a hyperhemolytic crisis? a. A preschooler with dyspnea, chest pain, temp 102.4, RR 42, shallow b. A toddler with temp 100.8, yellow sclera, hgb 8.6, retic count 4.2% c. A school age child with a BP 70/48, splenomegaly, faint distal pulses d. An adolescent with abdominal pain, temp 101.4, oral retic count 8.2%
Ans b
Which of the following symptoms assessed by the nurse would indicate heart failure in a child with a ventricular septal defect? A. Diaphoresis, nausea & vomiting and tingling in extremities B. Hepatomegaly, jugular venous distension & peripheral edema C. Falling blood pressure, falling pulse rate, increased respirations D. Rales & Rhonchi, falling oxygen saturation, labored breathing
Ans b
The client diagnosed with type 2 diabetes is admitted to the intensive care unit (ICU) with hyperosmolar hyperglycemic nonketotic syndrome (HHNS). Which clinical assessment data is most appropriate for the nurse to monitor? Select all that apply. (The wording of the question seems like it came from MS success CH. 8, #13 but the answer choices are all different) A. Postural hypertension B. Increased osmolality level C. Elevated BUN D. Decreased osmolality level
Ans b c
The nurse is caring for an infant 24hours post-op open heart surgery to repair a congenital heart defect. Which of the following would be included in the nurse priority assessments? select all that apply? A. Asses for skin breakdown B. Lung sounds, respiratory effort and peripheral edema C. Heart rate and blood pressure D. EKG on heart monitor E. Asses pulses and cap refills
Ans b c d e
A patient with metastatic breast cancer has been diagnosed with the syndrome of inappropriate antidiuretic hormone (SIADH). Which of the following assessment findings best represents SIADH? Select all that apply. Urine specific gravity 1.003 [SHOULD BE GREATER THAN 1.005] Serum osmolality 250 mosm/L Sodium level 160 mEq/L Serum sodium level of 120 mEq/L
Ans b d
A diabetic client received 10units of Novolog at 0700. At 1000am the unlicensed assistive personnel (UAP) tells the nurse the client has a headache and is really acting "funny." Which intervention should the nurse implement first? (Med Surg Success--CH 8, #10) A. Instruct the UAP to obtain the blood glucose level B. Prepare to administer one (1) ampule 50% dextrose hypoglycemia C. Go to the client's room and asses the clients for hypoglycemia D. Have the UAP to give the client four (4) ounces of apple juice to drink.
Ans c
A labor and delivery nurse is caring for a patient who is 30 weeks gestation, with a complete placenta previa. Which of the following doctors orders should the nurse question? (Maternal Newborn Success--CH 9, #52) A. Administer Betamethasone (Celestone) 12mg IM now, then repeat in 24hours B. Maintain strict bed rest C. Assess cervical dilation D. Regulate intravenous infusion of Ringer's Lactate at 125ml/hour.
Ans c
A macrosomic infant of a non-insulin dependent diabetic mother has been admitted to the neonatal nursery. The infant's glucose level on admission is 20 mg/dl. After breastfeeding, the serum glucose is 30mg/dl. Which of the following actions should the nurse take at this time? a. Administer IV glucagon slowly over 5 minutes b. No intervention is necessary because all data are within normal limits c. Notify the neonatologist of the abnormal glucose level d. Feed the infant a bottle of dextrose and water and reassess the serum glucose le
Ans c
A macrosomic infant of a non-insulin dependent diabetic mother has been admitted to the neonatal nursery. The infant's glucose levels on admission is 20mg/dl. After breastfeeding the serum glucose is 30mg/dL. Which of the following actions should the nurse take at this time? A. Administer IV glucagon slowly over five minutes B. No intervention is necessary because all data are within normal limits C. Notify the neonatologist of the abdominal glucose level D. Feed the infant a bottle of dextrose and water and reassess the serum glucose level
Ans c
A nursing is instructing a client in regard to permanent diabetes insipidus (DI) prior to discharge. Which of the following instructions provided by the nurse is most appropriate? A. "Continue vasopressin therapy until symptoms disappear." B. "Monitor for recurrence of swelling of the hands and the inability to urinate." C. "Monitor for recurrence of extreme thirst and urination." D. "Monitor and record weight twice a week."
Ans c
A patient admitted with the diagnosis DKA received 10 units of novolog insulin subcutaneously and 5 units of regular insulin IV at 5am. The patient is alert, groggy in appearance and has a blood sugar of 450 mg/dl. Four (4) hours later the patient's "re-checked" blood sugar is 300mg/dL. Which of the following actions is most appropriate for the nurse to implement? A. Administer Glucagon 1mg IM to prevent hypoglycemia B. Calling the results of a Magnesium level of 1.8mg/dL to the physician C. Administering 20units of Lantus (Glargine) subcutaneously as ordered on the medication administration for 9 am D. Calling the results of a 8 HbA1C level to the physician
Ans c
A patient with metastatic lung cancer has developed SIADH. The nurse correlates which finding to diagnosis of SIADH? a. Polyuria b. Polyphagia c. Decreased urine output d. Decreased urine specific gravity
Ans c
A primigravida is admitted with an unruptured ectopic pregnancy which is less than 3.5 centimeters in diameter. She and her husband have been trying to conceive for over a year. Which order would you anticipate the doctor to place? A. Preoperative orders for a bilateral tubal ligation B. Preoperative orders for a salpingectomy C. Methotrexate 50mg/m2 intramuscularly D. Pitocin 2 mU/hour intravenously
Ans c
An osteosarcoma patient is receiving Methotrexate as part of their chemotherapy regimen. Prior to administering this drug the patient is given a fluid bolus and receives a high IV fluid rate during administration of this chemo-drug. Which medication will the nurse expect to order to decrease fluid overload in the brain? A. Acetaminophen (Tylenol) B. Ondansetraon (Zofran) C. Dexamethasone (Decadron) D. Methylprednisolone (Solu-medrol)
Ans c
Children with sickle cell disease often have hyper-hemolytic crisis episodes. The nurse would recognize which of the following signs or symptoms as a clue to this type of crisis A. Hypotension, splenomegaly, faint distal pulses B. Dyspnea, chest pain, fever, tachypnea C. Fever, jaundice, Hgb 6.8, retic count 1.2% D. Abdominal pain, fever, retic count 2.7%
Ans c
How are placenta previa and abruptio different? (Similar to Maternal Newborn Success CH 9, #49) A. Abruptio placenta is associated with painless bleeding and placenta previa is associated with painful bleeding B. Abruptio placenta causes hemorrhage and placenta previa does not C. Abruptio placenta is associated with a board like abdomen and placenta previa is associated with a soft relaxed uterus D. Placenta previa begins suddenly, without warning and abruptio placenta has a slow gradual onset.
Ans c
How are placenta previa and abruptio placenta different? a. Abruptio placenta is associated with painless bleeding and placenta previa is associated with painful bleeding b. Abruptio placenta causes hemorrhage and placenta previa does not c. Abruptio placenta is associated with a board-like abdomen and placenta previa is associated with a soft, relaxed uterus d. Placenta previa begins suddenly, without warning and abruptio placenta has a slow, gradual onset
Ans c
The nurse is reviewing the prenatal history of a patient that is 12 weeks gestation. She is a 23 year old, Caucasian, G1, of normal weight and does not have a history of glucose intolerance. Her mother is a type 2 diabetic. Select the MOST appropriate statement: A. She is at high risk and should be tested at 28weeks B. She is of low risk and should not be tested C. She is of high risk and should be tested at this visit D. She is of low risk and needs to be tested at 24 weeks.
Ans c
What does HELLP stand for? a. Hemolysis, Eclampsia, Low platelets, and Liver labs b. Hypertension, Elevated Liver Enzymes, and Low platelets c. Hemolysis, Elevated Liver Enzymes, and Low platelets d. Hypertension, Edema, Liver involvement, Low Platelets
Ans c
Which of the findings is indicative of HELLP syndrome? A. Elevated blood pressure B. Seizures C. Epigastric pain D. Edema of the face, hands, and feet
Ans c
Which of the following patients is in aplastic crisis? A. 6 year old was brought to the ER because difficult to arouse. GCS 12, Hgb 4.6g/dL, Retic count 3.2%, pulse 125, BP 74/45, cap refill on toes <3sec bilaterally B. 4 year old admitted with jaundice sclera, scratches noticed to arms and abdomen, Hgb 5.4 g/dL, retic count 3.8%, K+ 5.6mEq/L C. 3 year old with history of viral illness, pale, decrease energy, Hgb 3.5 g/dL, retic count 0.2% D. 5 year old with one week history of upper respiratory infection, rales in lower left base, abdominal pain, WBC 19.1/mm3, Hgb 7.8 g/dL, retic count 10.2%
Ans c
Which statement made by the nurse would be correct when instructing the patient on postpartum management of gestational diabetes? A. "It's very possible that you will not develop this with future pregnancies." B. "Because you did not receive insulin during pregnancy you may need insulin now." C. "Breastfeeding helps to lower your blood glucose level." D. "The doctor will need to monitor your blood glucose once a week for the next 6 weeks."
Ans c
An infant is suspected of having Tetralogy of Fallot. When reading the ECHO report, the nurse would expect which of the following defects to be present? Select all that apply. A. Atrial septal defect B. Left Ventricular Hypertrophy C. Pulmonic Stenosis D. Overriding aorta E. Right ventricular hypertrophy
Ans c d e
The nurse is admitting a 3-year-old boy with suspected Kawasaki disease from the pediatrician's office. What will the nurse include in the priority assessment of this patient? SATA. a. Peripheral pulses and cap refill b. Anterior fontanel c. Mucous membranes d. Vital signs e. Immunization history
Ans c d e
A patient with a diagnosis of diabetic ketoacidosis (DKA) is being treated in the emergency room. Which assessment finding would a nurse expect to observe in a patient with this diagnosis? (I found some similar questions that I'm adding to the 237 Test 2 Quizlet folder) A. Comatose state B. Decreased urine output C. Increased respirations and an increase in pH D. Elevated blood glucose levels and a low plasma bicarbonate
Ans d
A patient with the diagnosis of diabetes ketoacidosis (DKA) is being treated in the emergency department. Which of the following clinical symptoms best represents this acute diabetic complication? A. Diaphoresis blood glucose 350 mg/dL BUN 40mg/dL B. PCo2 level of 60, pH 7.33, HCO3 22 on arterial blood gases, blood glucose 350mg/dL C. BUN 5mg/dL, blood glucose 350mg/dL, serum osmolality level 250 mosm/L D. BUN 40, blood glucose 350 mg/dL, serum osmolality 330mosm/L
Ans d
Nursing assessment for the patient with hydramnios will include which of the following? Select all that apply. A. Assess this patient amnioinfusion B. Assess patient for contractions and dyspnea C. Assess patient for signs of impending seizures D. Assess patient for signs of premature rupture of membrane (PROM) E. Assess patient for effectiveness of Pitocin induction
Ans d
The nurse is caring for a patient who was just admitted to the hospital to rule out ectopic pregnancy. Which of the following actions is most important for the nurse to perform? (Maternal Newborn Success--CH 8, #37) A. Assess the patient's temperature B. Document the time of the patients last meal C. Obtain urine urinalysis and culture D. Report complaints of dizziness & weakness
Ans d
A patient diagnosed with oligohydramnios is laboring at 37-week gestation. The nurse recognizes that variable decelerations on the fetal monitoring strop during the labor process is due to (multiple choice) (Close to Maternal Newborn Success CH 9, #109) A. Gestational diabetes B. Cord Compression [VEAL......CHOP] C. Jaundice D. Uteroplacental insufficiency
Answer B
The nurse tech just charted the admission vital signs of a 6year old boy as T 103.3, R 24, Pulse 119, BP 110/70. His height is 112 cm and his weight is 20.2 kg. the nurse would classify this patient BP as__________?
BP Normal Ranges Normal: < 90th percentile Pre-HTN: Between 90th - <95th percentile [meaning 90-94th percentile] HTN: > or = 95th percentile [meaning 95, 96, 97 etc... ]
During a follow-up visit, the parents of a 5-month-old infant diagnosed with congenital heart disease tells the nurse, "We're just so tired and emotionally spent. All these tests and examinations are overwhelming. We just want to have a normal life. We're so focused on the baby that it seems like our 3-year-old is lost in the shuffle." Which intervention would be most helpful for this family? a. Have the parents bring the toddler with them to the hospital or appointments so they can spend time as a family. b. Encourage the parents to have a trusted family member stay with the infant so they could take their 3-year-old to the zoo for the day. c. Encourage the parents to have a trusted family member keep the children so they can have a dinner date. d. Take the family on a vacation to the beach.
B
The nurse is caring for a newborn diagnosed with an atrial septal defect. The parents voice concern and state, "I can't believe this is happening. Will our child be okay?" What is the nurse's best response? a. "Since there are no symptoms being exhibited right now, your child will likely not require surgery until the age of 3." b. "While each case is different, the majority of these defects correct on their own. Let's see what the tests show, then speak with the doctor." c. "If the defect isn't treated, it can cause problems such as pulmonary hypertension, heart failure, atrial arrhythmias and stroke." d. "Most children have no symptoms of this defect."
B
An infant is suspected of having tetralogy of fallot. When reading the echo report, the nurse would expect which of the following defects to be present? SATA. a. Left ventricular hypertrophy b. Pulmonic stenosis c. Overriding aorta d. Atrial septal defect
B c
A patient is brought to the emergency department by the paramedics. The patient is a type 2 diabetic and is experiencing HHS. The nurse should identify what components of HSS? SATA. a. Leukocytosis b. Glycosuria c. Dehydration d. Hypernatremia e. Hyperglycemia
B c d e
A nurse caring for a patient with diabetes insipidus is reviewing laboratory results. What is an expected urinalysis finding? a. Glucose in the urine b. Albumin in the urine c. Highly dilute urine d. Leukocytes in the urine
C
A patient has been brought to the ED by paramedics after being found unconscious. The patient's medic alert bracelet indicates that the patient has type 1 diabetes and the patient's blood glucose is 22 mg/Dl. (1.2 mmol/l). The nurse should anticipate which intervention? a. IV bolus of 5% dextrose in 0.45% NaCl b. Subcutaneous administration of 12 to 15 units of regular insulin c. IV administration of 50% dextrose in water d. Subcutaneous administration of 10 units of Humalog
C
A patient is admitted with diabetic ketoacidosis (DKA), received 15 units of Novolog insulin subcutaneously on admission by the nurse as ordered by the physician. The patient's blood sugar on admissions was 350mg/dl. One hour later the patient states "I feel weak and shaky." Which intervention should the nurse implement first? a. Administer IV dextrose 50%, one ampule according to the hypoglycemic protocol b. Administer 8 ounces of orange juice to the patient c. Notify the HCP immediately d. Check the patient's blood sugar
C
The least invasive treatment for the heart defect pictured below involves which of the following? a. Thoracotomy to place band on PDA b. Incision with purse string repair c. Administration of indomethacin d. Closure with a trans-catheter occluder device (cardioseal)
C
The client diagnosed with hyperglycemic hyperosmolar nonketotic syndrome (HHNS) is admitted to the ICU with a blood glucose level of 780 mg/dl. The patient is placed on an IV insulin infusion and appears groggy in appearance. Three hours later the client's blood glucose level registers 300 mg/dl. Which intervention should the nurse implement first? a. Increase the regular insulin IV infusion b. Check the client's urine for ketones c. Provide the client a meal d. Notify the healthcare provider
D
The nurse is assessing a 3-year-old boy whose parents brought him to the clinic when they noticed that the right side of his abdomen was swollen. What findings would suggest that this child has a neuroblastoma? a. The child has a maculopapular rash on his palms b. The parents report that their son is active in normal activities and eating well c. Auscultation reveals wheezing with diminished lung sounds d. The parents report that their son is irritable and not gaining weight
D
The nurse tech just charted the admission vital signs of a 5 year old boy at T 100.4, R 32, Pulse 126, BP 116/75. His height is 113 cm (75th percentile) and his weight is 14.3 kg. The nurse would classify this patient's BP as?
Hypertensive
What type of congestive heart failure would be present in a child with the congenital heart defect is shown bellow
PDA
