Nokea
In which congenital heart defect (CHD) would the nurse need to take upper and lower extremity BPs?
- A. Transposition of the great vessels
- B. Aortic stenosis (AS)
- C. Coarctation of the aorta (COA)
- D. Tetralogy of Fallot (TOF)
Correct Answer: C
Rationale: COA causes increased blood pressure and strong pulses in the upper extremities with lower-than-expected BP and weak pulses in the lower extremities.
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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.
Sodium valproate is used in all types of seizures except:
- A. Absences
- B. Infantile spasms
- C. Generalised clonic seizures
- D. Myoclonic type
Correct Answer: B
Rationale: Infantile spasms: Sodium valproate is not the first-line treatment for infantile spasms. Vigabatrin is preferred due to its effectiveness in this condition.
Which is best described as the inability of the heart to pump an adequate amount of blood to the systemic circulation at normal filling pressures?
- A. Pulmonary congestion
- B. Congenital heart defect
- C. Heart failure
- D. Systemic venous congestion
Correct Answer: C
Rationale: The definition of heart failure is the inability of the heart to pump an adequate amount of blood to the systemic circulation at normal filling pressures to meet the body’s metabolic demands. Pulmonary congestion is an excessive accumulation of fluid in the lungs. Congenital heart defect is a malformation of the heart present at birth. Systemic venous congestion is an excessive accumulation of fluid in the systemic vasculature.
Which is the most appropriate nursing action related to the administration of digoxin (Lanoxin) to an infant?
- A. Counting the apical rate for 30 seconds before administering the medication
- B. Withholding a dose if the apical heart rate is less than 100 beats/min
- C. Repeating a dose if the child vomits within 30 minutes of the previous dose
- D. Checking respiratory rate and blood pressure before each dose
Correct Answer: B
Rationale: As a rule, if the pulse rate of an infant is below 100 beats/min, the medication is withheld and the physician is notified.
The nurse assesses a client being treated for Herpes Zoster (shingles). Which assessments should the nurse include when evaluating the effectiveness of treatment? (Select all that apply)
- A. Skin integrity
- B. Functional ability
- C. Heart sounds
- D. Pain scale
Correct Answer: A
Rationale: These assessments help determine the effectiveness of treatment in managing pain, skin lesions, and the client's ability to perform daily activities.