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The Foley Family is caring for their youngest child, Justin, who is suffering from tetralogy of Fallot. Which of the following are defects associated with this congenital heart condition?
- A. Aorta exits from the right ventricle, pulmonary artery exits from the left ventricle, and two noncommunicating circulations
- B. Ventricular septal defect, overriding aorta, pulmonic stenosis (PS), and right ventricular hypertrophy
- C. Coarctation of aorta, aortic valve stenosis, mitral valve stenosis, and patent ductus arteriosus
- D. Tricuspid valve atresia, atrial septal defect, ventricular septal defect, and hypoplastic right ventricle
Correct Answer: B
Rationale: Tetralogy of Fallot is a congenital heart condition characterized by four specific defects:
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How many drops per minute should be delivered?
- A. 6
- B. 17
- C. 50
- D. 100
Correct Answer: B
Rationale: The standard drip factor for an IV infusion set is typically 15 drops per milliliter. To calculate drops per minute, you would multiply the flow rate in milliliters per hour by the drip factor and divide by 60 minutes per hour.
A preschool child is scheduled for an echocardiogram. Parents ask the nurse whether they can hold the child during the procedure. The nurse should answer with which response?
- A. "You will be able to hold your child during the procedure."
- B. "Your child can be active during the procedure, but can't sit in your lap."
- C. "Your child must lie quietly; sometimes a mild sedative is administered before the procedure."
- D. "The procedure is invasive so your child will be restrained during the echocardiogram."
Correct Answer: A
Rationale: The correct response is that "You will be able to hold your child during the procedure." It is common for parents to be allowed to hold their child during an echocardiogram to provide comfort and reassurance. This can help the child stay calm and cooperative during the procedure. Holding the child can also create a familiar and secure environment, making it easier for the healthcare provider to perform the echocardiogram successfully.
Which intervention should the nurse implement to maintain the skin integrity of the preterm newborn?
- A. Cleanse skin with a gentle alkaline-based soap and water.
- B. Cleanse skin with a neutral pH solution only when necessary.
- C. Thoroughly rinse skin with plain water after bathing in a mild hexachlorophene solution.
- D. Avoid cleaning skin.
Correct Answer: B
Rationale: Preterm newborns have delicate skin that is more susceptible to damage and irritation. Using a neutral pH solution for cleansing helps to maintain the skin's natural acidity and prevent disruption of the skin barrier. It is important to avoid over-bathing or using harsh alkaline-based soaps that can strip the skin of its natural oils and cause dryness or irritation. Cleansing the skin only when necessary helps to protect the fragile skin of preterm newborns and reduce the risk of skin breakdown or injury.
Blood and fluid loss from frequent diarrhea may cause hypovolemia and you can quickly assess volume depletion in Miss CC by:
- A. Measuring the quantity and specific gravity of her urine output
- B. Taking her blood pressure
- C. Comparing the patient's present weight with her last weight
- D. Administering the oral water test
Correct Answer: C
Rationale: Comparing the patient's present weight with her last weight is the best way to quickly assess volume depletion in Miss CC. As she has been experiencing frequent diarrhea leading to blood and fluid loss, changes in weight are a reliable indicator of changes in the body's fluid status. A significant decrease in weight would suggest a loss of fluid and potential hypovolemia due to the diarrhea. This method is simple, immediate, and directly reflects the impact of the fluid loss on the body's volume status. Measuring the quantity and specific gravity of her urine output could provide information on her kidney function but may not be as quick and direct in evaluating volume depletion as comparing her current weight with her last recorded weight. Taking her blood pressure is important in assessing overall cardiovascular status but may not be as immediate in reflecting the impact of fluid loss on volume status. Administering the oral water test is not a standard method for quickly assessing volume depletion in this scenario.
A nurse is collecting subjective and objective information about target populations to diagnose problems based on community needs. This describes which step in the community nursing process?
- A. Planning
- B. Diagnosis
- C. Assessment
- D. Establishing objectives
Correct Answer: C
Rationale: In the community nursing process, the step of collecting subjective and objective information about target populations to diagnose problems based on community needs is known as "Assessment." This step involves gathering data through observation, interviews, surveys, and other methods to understand the health status, priorities, assets, and resources of the community. This information is essential for identifying the health needs and issues within the community, which then informs the planning and implementation of appropriate interventions. Assessment helps nurses develop a comprehensive understanding of the community's strengths, challenges, and opportunities, enabling them to make informed decisions and tailor interventions to meet the specific needs of the target population.