Nokea
An adult client is admitted with flank pain and is diagnosed with acute pyelonephritis. What is the priority nursing action?
- A. Auscultate for presence of bowel sounds.
- B. Monitor hemoglobin and hematocrit
- C. Encourage turning and deep breathing
- D. Administer IV antibiotics as prescribed.
Correct Answer: D
Rationale: Administering IV antibiotics promptly is critical to treat the infection and prevent complications in acute pyelonephritis.
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Down syndrome and VSD
- A. Doesn't close spontaneously as in children without downs
- B. Inaudible murmur is a characteristic feature / Murmur is not audible
- C. Pulmonary Hypertension is a late complication
- D. If no murmur, condition need not be investigated
Correct Answer: C
Rationale: Pulmonary hypertension is a known late complication in Down syndrome with VSD.
A previously well 3½-month-old presents with poor feeding, diaphoresis during feeding, and poor growth. Vital signs reveal respirations of 70, pulse of 175, and blood pressure of 90/65 mm Hg in the upper and lower extremities. The cardiac examination reveals a palpable parasternal lift and a systolic thrill. A grade 4 holosystolic murmur and a mid-diastolic rumble are noted. The chest radiograph reveals cardiomegaly. The most likely diagnosis is
- A. cardiomyopathy
- B. myocarditis
- C. VSD
- D. coarctation of the aorta
Correct Answer: C
Rationale: The presentation suggests a large ventricular septal defect (VSD) causing significant left-to-right shunting and heart failure.
All of the following are useful indicators regarding the severity of Tetralogy of Fallot
- A. Systemic arterial oxygen saturation
- B. Intensity of outflow murmur
- C. Functional class
- D. Right ventricular outflow gradient by echocardiography
Correct Answer: B
Rationale: The intensity of the outflow murmur is not a reliable indicator of the severity of Tetralogy of Fallot.
What are TWO possible interventions for an infant with Tetralogy of Fallot who has recurrent desaturation episodes on propranolol?
- A. Full surgical repair
- B. Interim repair with RVOT stent or shunt
- C. Propranolol dose adjustment
- D. All of the above
Correct Answer: B
Rationale: Interim repair with RVOT stent or shunt can be used to improve oxygenation in infants who are not candidates for immediate full surgical repair.
Nurse Kelly is teaching the parents of a young child how to handle poisoning. If the child ingests poison, what should the parents do first?
- A. Administer ipecac syrup
- B. Call an ambulance immediately
- C. Call the poison control center
- D. Punish the child for being bad
Correct Answer: C
Rationale: Calling the poison control center provides immediate guidance on how to handle the specific type of poisoning and whether further medical intervention is needed.