Nokea
David, age 15 months, is recovering from surgery to remove Wilms’ tumor. Which findings best indicates that the child is free from pain?
- A. Decreased appetite
- B. Increased heart rate
- C. Decreased urine output
- D. Increased interest in play
Correct Answer: D
Rationale: Increased interest in play is a positive sign that the child is not experiencing significant pain and is recovering well.
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The nurse is providing preoperative education for a Jewish client scheduled to receive a xenograft graft to promote burn healing. Which information should the nurse provide this client?
- A. Grafting increases the risk for bacterial infections
- B. The xenograft is taken from nonhuman sources
- C. Grafts are later removed by a debriding procedure
- D. As the burn heals, the graft permanently attaches
Correct Answer: B
Rationale: This information is crucial for the client to understand the nature of the graft and its source.
The following are major side effects of PGE1 EXCEPT
- A. apnea
- B. fever
- C. cutaneous flushing
- D. hypertension
Correct Answer: D
Rationale: Cutaneous flushing is a common side effect of PGE1, while hypertension is not typically observed.
A child has been diagnosed with valvular disease following rheumatic fever (RF). During patient teaching, the nurse discusses the child’s long-term prophylactic therapy with antibiotics for dental procedures, surgery, and childbirth. The parents Indicate they understand when they say:
- A. “She will need to take the antibiotics until she turns 18 years old.â€
- B. “She will need to take the antibiotics for 5 years after the last attack.â€
- C. “She will need to take the antibiotics for 10 years after the last attack.â€
- D. “She will need to take the antibiotics for the rest of her life.â€
Correct Answer: D
Rationale: Lifelong antibiotic prophylaxis is recommended for individuals with valvular disease following rheumatic fever to prevent recurrent infections and further cardiac damage.
The nurse is assessing a child after a cardiac catheterization. Which complication should the nurse be assessing for?
- A. Cardiac arrhythmia
- B. Hypostatic pneumonia
- C. Heart failure
- D. Rapidly increasing blood pressure
Correct Answer: A
Rationale: Because a catheter is introduced into the heart, a risk exists of catheter-induced dysrhythmias occurring during the procedure. These are usually transient. Hypostatic pneumonia, heart failure, and rapidly increasing blood pressure are not risks usually associated with cardiac catheterization.
During a well-child checkup for an infant with tetralogy of Fallot (TOF), the child develops severe respiratory distress and becomes cyanotic. The nurse's first action should be to:
- A. Lay the child flat to promote hemostasis
- B. Lay the child flat with legs elevated to increase blood flow to the heart
- C. Sit the child on the parent's lap, with legs dangling, to promote venous pooling
- D. Hold the child in knee-chest position to decrease venous blood return
Correct Answer: D
Rationale: The knee-chest position increases systemic vascular resistance (SVR), which increases blood flow to the pulmonary artery.