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A nurse assesses a client who is recovering from a myocardial infarction. The client’s pulmonary artery pressure reading is 25/12 mm Hg. Which action should the nurse take first?
- A. Compare the results with previous pulmonary artery pressure readings.
- B. Increase the intravenous fluid rate because these readings are low.
- C. Immediately notify the health care provider of the elevated pressures.
- D. Document the finding in the client’s chart as the only action.
Correct Answer: A
Rationale: Comparing the current pulmonary artery pressure readings with previous ones helps determine if the values are stable or changing, which guides further intervention.
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The nurse is caring for a child with acute glomerulonephritis. Which of the following would most likely indicate that the child’s condition is improving?
- A. Increased urine output with normal color and consistency
- B. Decrease in the blood pressure
- C. A reduction in protein levels in the urine
- D. A decrease in hematuria
Correct Answer: A
Rationale: Improved renal function is indicated by increased urine output and the return of urine to normal color and consistency.
The nurse is collecting information from a client with chronic pancreatitis who reports persistent gnawing abdominal pain. To help the client manage the pain, which assessment data is most important for the nurse to obtain?
- A. Eating patterns and dietary intake
- B. Level and amount of physical activity
- C. Color and consistency of feces
- D. Presence and activity of bowel sounds
Correct Answer: A
Rationale: Eating patterns can affect the pain and inflammation in chronic pancreatitis, making this data crucial.
The most common cardiac dysrhythmia in pediatrics is:
- A. Ventricular tachycardia
- B. Sinus bradycardia
- C. Supraventricular tachycardia
- D. First-degree heart block
Correct Answer: C
Rationale: SVT is the most common dysrhythmia in children.
A wide splitting of S2 during expiration is auscultated in a 2-week-old infant.
- A. Atrial septal defect (ASD)
- B. Coarctation of the aorta (COA)
- C. Patent ductus arteriosis (PDA)
- D. Ventricular septal defect (VSD)
Correct Answer: A
Rationale: A wide splitting of S2 without becoming a single sound on expiration may indicate increased pulmonary flow, typical of atrial septal defect.
Examples of cyanotic heart disease include:
- A. Ebstein's anomaly
- B. Pulmonary stenosis
- C. Coarctation of aorta
- D. Hypoplastic left heart syndrome
Correct Answer: D
Rationale: Hypoplastic left heart syndrome is a form of cyanotic heart disease. Ebstein's anomaly and pulmonary stenosis can also cause cyanosis, but coarctation of the aorta typically does not.