Cardiovascular d/o
A nurse is caring for an infant. Which of the following are clinical manifestations of coarctation of the aorta? (Select all that apply.) A. Weak femoral pulses B. Cool skin of lower extremities C. Severe cyanosis D. Clubbing of the fingers E. Heart failure
A. CORRECT: Narrowing of the lumen of the aorta results in obstruction of blood flow from the ventricle, resulting in weak or absent femoral pulses. B. CORRECT: Narrowing of the lumen of the aorta results in obstruction of blood flow from the ventricle, resulting in cool skin of the lower extremities. C. INCORRECT: A client who has coarctation of the aorta exhibits adequate oxygenation of blood. Therefore, severe cyanosis is not present. D. INCORRECT: Clubbing of the fingers is a clinical manifestation of chronic hypoxemia and will not be observed in an infant who has coarctation of the aorta. E. CORRECT: Heart failure occurs when the heart is unable to meet the body's demands, and is a clinical manifestation of coarctation of the aorta.
A nurse is caring for a child who is suspected of having rheumatic fever. Which of the following manifestations support this diagnosis? (Select all that apply.) A. Erythema marginatum (rash) B. Continuous joint pain of the digits C. Tender, subcutaneous nodules D. Decreased erythrocyte sedimentation rate E. Elevated C-reactive protein
A. CORRECT: Rheumatic fever is caused by Group A β-hemolytic streptococcus. An erythema marginatum (rash) is a clinical manifestation. B. INCORRECT: A client who has rheumatic fever exhibits migratory joint pain of the large joints. C. INCORRECT: A client who has rheumatic fever exhibits nontender subcutaneous nodules of bony prominences. D. INCORRECT: Rheumatic fever is caused by Group A β-hemolytic streptococcus, which results in an elevated erythrocyte sedimentation rate. E. CORRECT: Rheumatic fever is caused by Group A β-hemolytic streptococcus. An increase in C-reactive protein is a clinical manifestation
A nurse is assessing an infant. Which of the following should the nurse recognize as clinical manifestations of heart failure? (Select all that apply.) A. Bradycardia B. Cool extremities C. Peripheral edema D. Increased urinary output E. Nasal flaring
A. INCORRECT: A client who has heart failure will exhibit tachycardia as the heart attempts to meet the body's demands. B. CORRECT: A client who has heart failure will exhibit cool extremities as the heart is unable to adequately circulate oxygenated blood. C. CORRECT: A client who has heart failure will exhibit peripheral edema as the heart is unable to adequately circulate blood through the body and back to the heart. D. INCORRECT: With heart failure, the heart is unable to keep up with the body's demands. A decrease in urinary output is a clinical manifestation of heart failure. E. CORRECT: A client who has heart failure will exhibit nasal flaring due to inadequate oxygenation of blood
A nurse is providing teaching to the mother of an infant who is to start taking digoxin (Lanoxin). Which of the following instructions should the nurse include? A. "Do not offer your baby fluids after giving the medication." B. "Digoxin increases your baby's heart rate." C. "Give the correct dose of medication at regularly scheduled times." D. "If your baby vomits a dose, you should repeat the dose to ensure that he gets the correct amount."
A. INCORRECT: Digoxin can be given without regard to food or fluids. B. INCORRECT: Digoxin slows the heart rate by increasing contractility of the heart. C. CORRECT: The correct amount of digoxin should be administered at regularly scheduled times to maintain therapeutic blood levels. D. INCORRECT: It is not recommended to repeat digoxin following an emesis because it is impossible to determine how much medication was lost.
A nurse is caring for a 2-year-old child who is cyanotic and is in the hospital for a cardiac catheterization to repair cardiac defects. The child will be transferred to the pediatric ICU following the procedure. Which of the following is an appropriate nursing action when providing care to this child? A. Place on NPO status for 12 hr prior to the procedure. B. Check for iodine or shellfish allergies prior to the procedure. C. Elevate the affected extremity following the procedure. D. Limit fluid intake following the procedure
A. INCORRECT: The child should remain NPO 4 to 6 hr prior to the procedure. B. CORRECT: Iodine-based dyes may be used in this procedure, so the child is assessed for allergies to iodine or shellfish which could lead to anaphylaxis. C. INCORRECT: The affected extremity should be maintained in a straight position following the procedure. D. INCORRECT: Fluids should be encouraged after the procedure to maintain adequate urine output and promote excretion of the dye.
