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After returning from cardiac catheterization, the nurse determines that the pulse distal to the catheter insertion site is weaker. How should the nurse respond?
- A. Elevate the affected extremity.
- B. Notify the practitioner of the observation.
- C. Record data on the assessment flow record.
- D. Apply warm compresses to the insertion site.
Correct Answer: C
Rationale: A weaker pulse post-catheterization is expected initially and should be documented as a baseline for monitoring. The pulse should strengthen over hours. Elevation, warm compresses, or immediate notification are unnecessary unless neurovascular changes occur.
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A 2-year-old child is receiving digoxin (Lanoxin). The nurse should notify the practitioner and withhold the medication if the apical pulse is less than which rate?
- A. 60 beats/min
- B. 90 beats/min
- C. 100 beats/min
- D. 120 beats/min
Correct Answer: B
Rationale: For infants and young children, digoxin is withheld if the 1-minute apical pulse is below 90 beats/min to prevent toxicity. A rate of 60 is the adult threshold, and 100-120 beats/min are acceptable for administration.
What clinical manifestation is a common sign of digoxin toxicity?
- A. Seizures
- B. Vomiting
- C. Bradypnea
- D. Tachycardia
Correct Answer: B
Rationale: Vomiting, unrelated to feedings, is a common sign of digoxin toxicity due to its narrow therapeutic range. Seizures are not associated, bradycardia (not bradypnea or tachycardia) may occur, but vomiting is a key indicator.
The nurse is caring for a child with persistent hypoxia secondary to a cardiac defect. The nurse recognizes the risk of cerebrovascular accidents (strokes) occurring. What strategy is an important objective to decrease this risk?
- A. Minimize seizures.
- B. Prevent dehydration.
- C. Promote cardiac output.
- D. Reduce energy expenditure.
Correct Answer: B
Rationale: Preventing dehydration reduces stroke risk in hypoxic children with polycythemia, as dehydration increases blood viscosity. Seizure control, cardiac output, and energy expenditure are important but don?t directly address stroke risk.
What drug is an angiotensin-converting enzyme (ACE) inhibitor?
- A. Furosemide (Lasix)
- B. Captopril (Capoten)
- C. Chlorothiazide (Diuril)
- D. Spironolactone (Aldactone)
Correct Answer: B
Rationale: Captopril is an ACE inhibitor used in heart failure management. Furosemide is a loop diuretic, chlorothiazide acts on distal tubules, and spironolactone is a potassium-sparing diuretic, none of which are ACE inhibitors.
Decreasing the demands on the heart is a priority in care for the infant with heart failure (HF). In evaluating the infants status, which finding is indicative of achieving this goal?
- A. Irritability when awake
- B. Capillary refill of more than 5 seconds
- C. Appropriate weight gain for age 18
- D. Positioned in high Fowler position to maintain oxygen saturation at 90%
Correct Answer: C
Rationale: Appropriate weight gain indicates successful feeding and reduced caloric loss, reflecting decreased cardiac demand. Irritability and prolonged capillary refill suggest ongoing HF, and high Fowler positioning aids breathing but doesn?t confirm reduced cardiac strain.