Nokea
How would the nurse caring for an infant with congestive heart failure (CHF) modify feeding techniques to adapt for the child's weakness and fatigue? (Select all that apply.)
- A. Feeding more frequently with smaller feedings
- B. Using a soft nipple with enlarged holes
- C. Holding and cuddling the child during feeding
- D. Substituting glucose water for formula
Correct Answer: A
Rationale: Infants with CHF fatigue easily. Feeding can be given more frequently in smaller amounts through a soft, large-holed nipple. Formulas with a denser caloric content can be offered. The child may be encouraged to nurse if he or she is held.
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After a computer tomography (CT) scan with intravenous contrast medium, a client returns to the room complaining of shortness of breath and itching. Which intervention should the nurse implement?
- A. Call respiratory therapy to give a breathing treatment
- B. Send another nurse for an emergency tracheotomy set
- C. Prepare a dose of epinephrine (Adrenalin)
- D. Review the client's complete list of allergies
Correct Answer: C
Rationale: Shortness of breath and itching are signs of an allergic reaction to the contrast medium, and epinephrine is the first-line treatment for anaphylaxis.
The following syndromes are due to chromosomal abnormalities:
- A. Cri-du-chat syndrome
- B. Kearns-Sayre syndrome
- C. Marfan's syndrome
- D. Turner's syndrome
Correct Answer: D
Rationale: Turner's syndrome: Turner's syndrome is caused by a monosomy of the X chromosome (45,X), leading to characteristic features such as short stature and ovarian insufficiency.
Regarding resuscitation of a three-year old with asystole:
- A. Hypoxia is the commonest cause
- B. It commonly leads to ventricular fibrillation
- C. Intracardiac adrenaline is an absolute indication
- D. IV calcium gluconate is the first line of therapy
Correct Answer: A
Rationale: Hypoxia is the most common cause of asystole in children, emphasizing the importance of oxygenation during resuscitation.
A 10-year-old client contracted severe acute respiratory syndrome (SARS) when traveling abroad with her parents. The nurse knows she must put on personal protective equipment to protect herself while providing care. Based on the mode of SARS transmission, which personal protective should the nurse wear?
- A. Gloves
- B. Gown and gloves
- C. Gown, gloves, and mask
- D. Gown, gloves, mask, and eye goggles or eye shield
Correct Answer: D
Rationale: SARS is transmitted through droplets, so full protective gear, including eye protection, is necessary to prevent infection.
A 2-month-old male presents with tachycardia, dyspnea, tachypnea, and a gallop rhythm with no heart murmur. He was perfectly well until 1 day prior to the episode. The physical examination reveals a heart rate of 235, a temperature of 37.8°C, and a normal blood pressure with warm, well-perfused extremities. The most likely diagnosis is
- A. sepsis
- B. supraventricular tachycardia
- C. ingestion
- D. ventricular tachycardia
Correct Answer: B
Rationale: Supraventricular tachycardia can cause rapid heart rates and heart failure in infants.