Nokea
A nurse assesses a client who had a myocardial infarction and is hypotensive. Which additional assessment finding should the nurse expect?
- A. Heart rate of 120 beats/min
- B. Cool, clammy skin
- C. Oxygen saturation of 90%
- D. Respiratory rate of 8 breaths/min
Correct Answer: A
Rationale: A heart rate of 120 beats/min (tachycardia) is a common compensatory response to hypotension following a myocardial infarction, as the body attempts to maintain cardiac output.
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The nurse has provided home care instructions to the parents of a child who is being discharged after cardiac surgery. Which statement by the parents indicates a need for further instructions?
- A. “A balance of rest and exercise is important.â€
- B. “I can apply lotion or powder to the incision if it is itchy.â€
- C. “Activities in which my child could fall need to be avoided for 2-4 weeks.â€
- D. “We should avoid going to places like the mall or grocery stores for at least 2 weeks after surgery.â€
Correct Answer: B
Rationale: Applying lotion or powder to the incision can increase the risk of infection. Parents should be instructed to keep the incision clean and dry.
David, age 15 months, is recovering from surgery to remove Wilms’ tumor. Which findings best indicates that the child is free from pain?
- A. Decreased appetite
- B. Increased heart rate
- C. Decreased urine output
- D. Increased interest in play
Correct Answer: D
Rationale: Increased interest in play is a positive sign that the child is not experiencing significant pain and is recovering well.
Which among the following is a systolic event?
- A. E wave
- B. L wave
- C. A wave
- D. S' wave
Correct Answer: D
Rationale: S' wave is a systolic event observed in echocardiography.
A client who has a history of hypothyroidism was initially admitted with lethargy and confusion. Which additional finding warrants the most immediate action by the nurse?
- A. Facial puffiness and periorbital edema
- B. Hematocrit of 30%
- C. Cold and dry skin
- D. Further decline in level of consciousness
Correct Answer: D
Rationale: A further decline in level of consciousness could indicate myxedema coma, a life-threatening complication of hypothyroidism.
What does the surgical closure of the ductus arteriosus do?
- A. Stop the loss of unoxygenated blood to the systemic circulation
- B. Decrease the edema in legs and feet
- C. Increase the oxygenation of blood
- D. Prevent the return of oxygenated blood to the lungs
Correct Answer: D
Rationale: The ductus arteriosus allows blood to flow from the higher-pressure aorta to the lower-pressure pulmonary artery, causing a right-to-left shunt. If this is surgically closed, no additional oxygenated blood (from the aorta) will return to the lungs through the pulmonary artery. The aorta carries oxygenated blood to the systemic circulation. Because of the higher pressure in the aorta, blood is shunted into the pulmonary artery and the pulmonary circulation. Edema in the legs and feet is usually a sign of heart failure. This repair would not directly affect the edema. Increasing the oxygenation of blood would not interfere with the return of oxygenated blood to the lungs.