Nokea
An 8-month-old infant has a hypercyanotic spell while blood is being drawn. What is the priority nursing action?
- A. Assess for neurologic defects
- B. Place the child in the knee-chest position
- C. Begin cardiopulmonary resuscitation
- D. Prepare family for imminent death
Correct Answer: B
Rationale: The first action is to place the infant in the knee-chest position. Blow-by oxygen may be indicated. Neurologic defects are unlikely. The child should be assessed for airway, breathing, and circulation. Often, calming the child and administering oxygen and morphine can alleviate the hypercyanotic spell.
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The following are strongly associated with Kawasaki disease EXCEPT
- A. duration of fever of >16 days
- B. first-degree heart block
- C. male gender
- D. age of <1 year
Correct Answer: B
Rationale: First-degree heart block is less commonly associated with Kawasaki disease compared to other factors.
The nurse reviews the laboratory results of a client during an annual physical examination and identifies a positive guaiac test of stool. Which additional serum laboratory test result should the nurse review?
- A. Glucose
- B. Platelet count
- C. White blood cell count
- D. Amylase
Correct Answer: B
Rationale: A positive guaiac test indicates gastrointestinal bleeding. A platelet count is essential to assess for thrombocytopenia, which could contribute to bleeding.
Which finding might delay a cardiac catheterization procedure on a 1-year-old?
- A. 30th percentile for weight
- B. Severe diaper rash
- C. Allergy to soy
- D. Oxygen saturation of 91% on room air
Correct Answer: B
Rationale: A severe diaper rash may indicate potential infection, which is a contraindication for the standard groin approach during catheterization.
Regarding iron deficiency anemia, which of the following is true?
- A. Ferritin levels are elevated
- B. Red blood cell count is usually normal
- C. Hemoglobin is usually decreased
- D. Serum iron levels are elevated
Correct Answer: C
Rationale: In iron deficiency anemia, hemoglobin levels are usually decreased due to insufficient iron for red blood cell production.
All of the following are part of acute aortic syndrome, except
- A. Aortic dissection
- B. Acute aortic regurgitation
- C. Intramural hematoma
- D. Penetrating atherosclerotic ulcer
Correct Answer: B
Rationale: Acute aortic regurgitation is not typically considered part of acute aortic syndrome.