Nokea
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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Which is a major clinical manifestation of rheumatic fever?
- A. Polyarthritis
- B. Osler nodes
- C. Janeway spots
- D. Splinter hemorrhages of distal third of nails
Correct Answer: A
Rationale: Polyarthritis, which is swollen, hot, red, and painful joints, is a major clinical manifestation of rheumatic fever. The affected joints will change every 1 to 2 days. Primarily the large joints are affected. Osler nodes, Janeway spots, and splinter hemorrhages are characteristic of infective endocarditis.
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.
What should the school nurse recommend when encouraging a heart-healthy diet for a child with high cholesterol?
- A. A fat intake reduction of 5-10% of total calories
- B. A fat intake reduction of 10-15% of total calories
- C. A fat intake reduction of 15-20% of total calories
- D. A fat intake reduction of 25-35% of total calories
Correct Answer: D
Rationale: For a child with increased cholesterol, a fat reduction of 25-35% of total calories with less than 75 saturated fat and less than 200 mg of cholesterol per day is advised.
What assessment(s) in a child with tetralogy of Fallot would indicate the child is experiencing a paroxysmal hypercyanotic episode? (Select all that apply.)
- A. Spontaneous cyanosis
- B. Dyspnea
- C. Weakness
- D. Dry cough
Correct Answer: C
Rationale: Indicators of a paroxysmal hypercyanotic episode or a tet episode are spontaneous cyanosis, dyspnea, weakness, and syncope.
Through what does the infant born with hypoplastic left heart syndrome acquire oxygenated blood?
- A. The patent ductus arteriosus
- B. A ventricular septal defect
- C. The closure of the foramen ovale
- D. An atrial septal defect
Correct Answer: D
Rationale: Because the right side of the heart must take over pumping blood to both the lungs and systemic circulation, the ductus arteriosus must remain open to shunt the oxygenated blood from the lungs.