Nokea
Blunt or shallow Y descent in jugular venous waveform is seen in all, except
- A. Tricuspid stenosis
- B. Cardiac tamponade
- C. Effusive-constrictive pericarditis
- D. Ebstein's anomaly
Correct Answer: D
Rationale: Ebstein's anomaly is not typically associated with a blunt or shallow Y descent in the jugular venous waveform.
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During a paracentesis, two liters of fluid are removed from the abdomen of a client with ascites. A drainage bag is placed, and 50 ml of clear, straw-colored fluid drains within the first hour. What action should the nurse implement?
- A. Palpate for abdominal distention
- B. Send fluid to the lab for analysis
- C. Continue to monitor the fluid output
- D. Clamp the drainage tube for 5 minutes
Correct Answer: C
Rationale: Monitoring fluid output is essential to assess for complications such as reaccumulation of fluid or bleeding.
A nursing action that promotes ideal nutrition in an infant with congestive heart failure (CHF) is:
- A. Feeding formula that is supplemented with additional calories.
- B. Allowing the infant to nurse at each breast for 20 minutes.
- C. Providing large feedings every 5 hours.
- D. Using firm nipples with small openings to slow feedings.
Correct Answer: A
Rationale: Supplementing formula with extra calories increases the caloric density to support growth in infants with CHF.
A child of 36 months would be expected to:
- A. Build a tower of 5 cubes
- B. Repeat back 5 digits
- C. Draw a man with a head and body
- D. Demonstrate symbolic play
Correct Answer: D
Rationale: At 36 months, a child is expected to demonstrate symbolic play. Building a tower of 5 cubes and drawing a man with a head and body are also typical milestones.
In hyper cyanotic spells in Fallots tetralogy
- A. Hypoxia is there
- B. Murmur disappear
- C. Right to left shunt increases
- D. Acidosis occur
Correct Answer: C
Rationale: During hypercyanotic spells in Tetralogy of Fallot, the right-to-left shunt increases, leading to worsening cyanosis.
What are the four structural heart anomalies that make up the tetralogy of Fallot? (Select the four that apply.)
- A. Hypertrophied right ventricle
- B. Patent ductus arteriosus
- C. Ventral septal defect
- D. Narrowing of pulmonary artery
Correct Answer: D
Rationale: The four anomalies that comprise tetralogy of Fallot are hypertrophied right ventricle, patent ductus arteriosus, stenosis of pulmonary artery, and dextroposition of the aorta.