Nokea
A 4-month-old infant with a ventricular septal defect (VSD) has dropped from the 20th percentile to the 5th for weight. What will the nurse practitioner recommend?
- A. Adding solid foods to the infant's diet to increase caloric intake
- B. Fortifying breast milk to increase the number of calories per ounce
- C. Stopping breastfeeding and giving 30 kcal/ounce formula
- D. Supplementing breastfeeding with 24 kcal/ounce formula
Correct Answer: B
Rationale: Infants with heart defects who have congestive heart failure (CHF) may need modification of formula or breast milk to increase calories. Fortifying breast milk is the first and best option.
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Clinical manifestations of hypoplastic left-heart syndrome in the 1st 48 hr of life include
- A. always obvious color
- B. deep-blue skin
- C. bounding peripheral pulses
- D. occasional association with Turner syndrome
Correct Answer: C
Rationale: Bounding peripheral pulses are not typical in hypoplastic left-heart syndrome.
After a computer tomography (CT) scan with intravenous contrast medium, a client returns to the room complaining of shortness of breath and itching. Which intervention should the nurse implement?
- A. Call respiratory therapy to give a breathing treatment
- B. Send another nurse for an emergency tracheotomy set
- C. Prepare a dose of epinephrine (Adrenalin)
- D. Review the client's complete list of allergies
Correct Answer: C
Rationale: Shortness of breath and itching are signs of an allergic reaction to the contrast medium, and epinephrine is the first-line treatment for anaphylaxis.
At birth, tunica intima of arterial wall contains all of the following, except
- A. Type IV collagen
- B. Laminin
- C. Endothelial cells
- D. Smooth muscle cells
Correct Answer: D
Rationale: Smooth muscle cells are not typically found in the tunica intima at birth.
A male client who had abdominal surgery 5 days ago, and hospitalized because of a surgical wound infection, tells the nurse that he feels like his insides just spilled out when he coughed. What action should the nurse take first?
- A. Notify the healthcare provider
- B. Assure the client that such feelings occur with wound infections
- C. Visualize the abdominal incision
- D. Obtain sterile towels soaked in saline
Correct Answer: C
Rationale: Visualizing the incision helps determine if dehiscence or evisceration has occurred, which requires immediate intervention.
A postoperative client reports incisional pain. The client has two prescriptions for PRN analgesia that accompanied the client from the postanasthesia unit. Before selecting which medication to administer, which action should the nurse implement?
- A. Document the client's report of pain in the electronic medical record
- B. Determine which prescription will have the quickest onset of action
- C. Compare the client's pain scale rating with the prescribed dosing
- D. Ask the client to choose which mediation is needed for pain
Correct Answer: C
Rationale: Comparing the pain scale rating with the prescribed dosing ensures that the appropriate medication is administered based on the severity of the pain.