Nokea
A 2-month-old male presents with tachycardia, dyspnea, tachypnea, and a gallop rhythm with no heart murmur. He was perfectly well until 1 day prior to the episode. The physical examination reveals a heart rate of 235, a temperature of 37.8°C, and a normal blood pressure with warm, well-perfused extremities. The most likely diagnosis is
- A. sepsis
- B. supraventricular tachycardia
- C. ingestion
- D. ventricular tachycardia
Correct Answer: B
Rationale: Supraventricular tachycardia can cause rapid heart rates and heart failure in infants.
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When explaining dietary guidelines to a client with acute glomerulonephritis (AGN), which instruction should the nurse include in the dietary teaching?
- A. Restrict sodium intake
- B. Encourage high-protein foods.
- C. Increase potassium intake.
- D. Decrease fluid intake.
Correct Answer: A
Rationale: Sodium restriction helps manage fluid retention and hypertension, which are common in AGN.
What does the nurse explain that a ventricular septal defect will allow?
- A. Blood to shunt left to right, causing increased pulmonary flow and no cyanosis
- B. Blood to shunt right to left, causing decreased pulmonary flow and cyanosis
- C. No shunting because of high pressure in the left ventricle
- D. Increased pressure in the left atrium, impeding circulation of oxygenated blood in the circulating volume
Correct Answer: A
Rationale: Pulmonary blood flow is increased when a ventricular septal defect exists. The blood shifts from left to right because of the higher pressure in the left ventricle. This particular shift does not cause cyanosis.
A client with multiple sclerosis has urinary retention related to sensorimotor deficits. Which action should the nurse include in the client's plan of care?
- A. Teach the client techniques for performing intermittent catheterization
- B. Increase the client's fluid intake to promote frequent urination.
- C. Suggest the use of incontinence pads for comfort
- D. Administer anticholinergic medications to enhance bladder function.
Correct Answer: A
Rationale: Intermittent catheterization helps manage urinary retention and prevents complications like urinary tract infections.
In which congenital heart defect (CHD) would the nurse need to take upper and lower extremity BPs?
- A. Transposition of the great vessels
- B. Aortic stenosis (AS)
- C. Coarctation of the aorta (COA)
- D. Tetralogy of Fallot (TOF)
Correct Answer: C
Rationale: COA causes increased blood pressure and strong pulses in the upper extremities with lower-than-expected BP and weak pulses in the lower extremities.
A female client who was involved in a motor vehicle collision is admitted with a fractured left femur which is immobilized using a fracture traction splint in preparation for an open reduction internal fixation (ORIF). The nurse determines that her distal pulses are diminished in the left foot. Which interventions should the nurse implement? (Select all that apply.)
- A. Offer ice chips and oral clear liquids
- B. Verify pedal pulses using a doppler pulse device
- C. Monitor left leg for pain, pallor, paresthesia, paralysis, pressure
- D. Evaluate the application of the splint to the left leg
Correct Answer: B
Rationale: These interventions assess and address potential vascular compromise, which is critical in a client with a fractured femur.