Nokea
An 8-year-old child is receiving digoxin (Lanoxin). The nurse should notify the practitioner and withhold the medication if the apical pulse is less than _____ beats/min.
- A. 60
- B. 70
- C. 90
- D. 100
Correct Answer: B
Rationale: If a 1-minute apical pulse is less than 70 beats/min for an older child, the digoxin is withheld; 60 beats/min is the cut-off for holding the digoxin dose in an adult. A pulse below 90 to 110 beats/min is the determination for not giving a digoxin dose to infants and young children.
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A 3-month-old infant who was previously healthy now has a persistent cough, bilateral lung crackles, and poor appetite. A grade III/VI, low-pitched, holosystolic murmur over the left lower sternal border and palpates the liver at one centimeter below the ribs. What diagnosis is likely?
- A. Atrial septal defect (ASD)
- B. Coarctation of the aorta (COA)
- C. Patent ductus arteriosis (PDA)
- D. Ventricular septal defect (VSD)
Correct Answer: D
Rationale: The symptoms above are characteristic of a VSD and may not present at birth but appear later as CHF becomes more pronounced.
Which type of shock is characterized by a hypersensitivity reaction causing massive vasodilation and capillary leaks, which may occur with drug or latex allergy?
- A. Neurogenic
- B. Cardiogenic
- C. Hypovolemic
- D. Anaphylactic
Correct Answer: D
Rationale: Anaphylactic shock results from extreme allergy or hypersensitivity to a foreign substance. Neurogenic shock results from loss of neuronal control, such as the interruption of neuronal transmission that occurs from a spinal cord injury. Cardiogenic shock is decreased cardiac output. Hypovolemic shock is a reduction in the size of the vascular compartment, decreasing blood pressure, and low central venous pressure.
In bronchopulmonary dysplasia:
- A. Lung compliance is increased
- B. Bronchial reactivity is increased
- C. Lung function typically improves with age
- D. Hyperinflation is an associated finding
Correct Answer: D
Rationale: Hyperinflation is a common finding in bronchopulmonary dysplasia due to lung damage and the need for prolonged mechanical ventilation.
Routine hearing tests in the community are usually based on:
- A. Distraction testing
- B. Auditory brainstem responses
- C. Evoked potentials
- D. Object discrimination
Correct Answer: A
Rationale: Distraction testing is a common method used in community settings to assess hearing in young children.
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.