Nokea
Congenital heart disease causing cyanosis without respiratory distress include EXCEPT
- A. tricuspid atresia
- B. aortic stenosis
- C. Ebstein anomaly
- D. pulmonary atresia
Correct Answer: B
Rationale: Tricuspid atresia, Ebstein anomaly, and pulmonary atresia can cause cyanosis without respiratory distress, while aortic stenosis typically does not.
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The nurse is conducting a staff in-service on congenital heart defects. Which structural defect constitutes tetralogy of Fallot?
- A. Pulmonic stenosis, ventricular septal defect, overriding aorta, right ventricular hypertrophy
- B. Aortic stenosis, ventricular septal defect, overriding aorta, right ventricular hypertrophy
- C. Aortic stenosis, atrial septal defect, overriding aorta, left ventricular hypertrophy
- D. Pulmonic stenosis, ventricular septal defect, aortic hypertrophy, left ventricular hypertrophy
Correct Answer: A
Rationale: Tetralogy of Fallot has these four characteristics: pulmonic stenosis, ventricular septal defect, overriding aorta, and right ventricular hypertrophy. There is pulmonic stenosis but not atrial stenosis in tetralogy of Fallot. Right ventricular hypertrophy, not left ventricular hypertrophy, is present in tetralogy of Fallot. Tetralogy of Fallot has right ventricular hypertrophy, not left ventricular hypertrophy, and an atrial septal defect, not aortic hypertrophy.
Which is/are true?
- A. Babies are able to respond to sounds in utero
- B. Full term babies at birth are unable to follow a large object with their eyes
- C. A 6-week-old infant would be able to follow a large object through an arc of 135°
- D. Growth velocity of head decreases with age
Correct Answer: A
Rationale: Babies can respond to sounds in utero, and head growth velocity does decrease with age. Full-term babies can follow large objects, and a 6-week-old can follow objects through a smaller arc.
Two days after a nephrectomy, the client reports abdominal pressure and nausea, which assessment should the nurse implement?
- A. Palpate the abdomen
- B. Measure hourly urine output
- C. Ambulate client in hallway
- D. Auscultate bowel sounds
Correct Answer: D
Rationale: Auscultating bowel sounds helps assess for any bowel obstruction or ileus, which could be contributing to abdominal pressure.
Which statement by the mother of a child with rheumatic fever (RF) indicates that she has an understanding of prevention for her other children?
- A. “Whenever one of them gets a sore throat, I will give that child an antibiotic.â€
- B. “There is no treatment since it is viral and must run its course.â€
- C. “If their culture is positive for group A streptococcus, I will give them a full course of their antibiotic.â€
- D. “If their culture is positive for staphylococcus A, I will give them a full course of their antibiotic.â€
Correct Answer: C
Rationale: A positive culture for group A streptococcus indicates a bacterial infection that requires a full course of antibiotics to prevent rheumatic fever, which can develop as a complication of untreated strep throat.
Adverse reactions to angiotensin-converting enzyme inhibitors (ACEIs) include the following EXCEPT
- A. hypotension
- B. hypokalemia
- C. maculopapular rash
- D. renal toxicity
Correct Answer: B
Rationale: ACEIs can cause hyperkalemia, not hypokalemia.