Nokea
A nurse assesses an older adult client who has multiple chronic diseases. The client’s heart rate is 48 beats/min. Which action should the nurse take first?
- A. Document the finding in the chart.
- B. Initiate external pacing.
- C. Assess the client’s medications.
- D. Administer 1 mg of atropine.
Correct Answer: C
Rationale: A heart rate of 48 beats/min (bradycardia) in an older adult with multiple chronic diseases may be due to medication side effects. Assessing the client’s medications is the first step to determine if any drugs are contributing to the bradycardia.
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All patients with clinical evidence of a PDA are at increased risk for endocarditis. As a result, patients with PDA should be considered for irreversible closure EXCEPT
- A. small, hemodynamically insignificant PDA
- B. small, hemodynamically significant PDA
- C. moderate PDA
- D. large PDA
Correct Answer: A
Rationale: Small, hemodynamically insignificant PDAs may not require closure.
While assessing a newborn with respiratory distress, the nurse auscultates a machine-like heart murmur. Other findings are a wide pulse pressure, periods of apnea, increased PaCO2, and decreased PO2. The nurse suspects that the newborn has:
- A. Pulmonary hypertension
- B. Patent ductus arteriosus (PDA)
- C. Ventricular septal defect (VSD)
- D. Bronchopulmonary dysplasia
Correct Answer: B
Rationale: A machine-like murmur is the hallmark of a PDA.
An older client is admitted after falling while walking. The left leg is externally rotated and shorter than the right leg, and the client is having severe pain and tingling in the left foot. The nurse is unable to palpate the left pedal pulses. Which action is most important for the nurse to implement?
- A. Use a doppler to assess bilateral pedal pulses
- B. Administer pain medication to relieve discomfort.
- C. Position the client’s left leg in a neutral position to reduce pain.
- D. Immobilize the left leg to prevent further injury.
Correct Answer: A
Rationale: Assessing pedal pulses with a doppler is critical to evaluate circulation and detect potential vascular compromise in the affected limb.
The following are examples of acquired heart disease. Select all that apply.
- A. Infective endocarditis
- B. Coarctation of the aorta
- C. Rheumatic fever (RF)
- D. Cardiomyopathy
Correct Answer: C
Rationale: Acquired heart diseases include conditions that develop after birth, such as infective endocarditis, rheumatic fever, cardiomyopathy, and Kawasaki disease. Coarctation of the aorta and transposition of the great vessels are congenital heart defects.
The nurse is closely monitoring the intake and output of an infant with heart failure who is receiving diuretic therapy. The nurse should use which most appropriate method to assess urine output?
- A. Inserting a foley catheter.
- B. Weighing the diapers.
- C. Comparing intake with output.
- D. Measuring the amount of water added to the formula.
Correct Answer: B
Rationale: Weighing diapers is a non-invasive and accurate method to assess urine output in infants, which is crucial for monitoring the effectiveness of diuretic therapy.