Nokea
The nurse explained how to position an infant with tetralogy of Fallot if the infant suddenly becomes cyanotic. Which statement by the father leads the nurse to determine he understood the instructions?
- A. If the baby turns blue, I will hold him against my shoulder with his knees bent up toward his chest.
- B. If the baby turns blue, I will lay him down on a firm surface with his head lower than the rest of his body.
- C. If the baby turns blue, I will immediately put the baby upright in an infant seat.
- D. If the baby turns blue, I will put the baby in supine position with his head elevated.
Correct Answer: A
Rationale: In the event of a paroxysmal hypercyanotic or tet spell, the infant should be placed in a knee-chest position.
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While assessing a newborn with respiratory distress, the nurse auscultates a machine-like heart murmur. Other findings are a wide pulse pressure, periods of apnea, increased PaCO2, and decreased PO2. The nurse suspects that the newborn has:
- A. Pulmonary hypertension
- B. Patent ductus arteriosus (PDA)
- C. Ventricular septal defect (VSD)
- D. Bronchopulmonary dysplasia
Correct Answer: B
Rationale: A machine-like murmur is the hallmark of a PDA.
An older adult with heart failure is hospitalized during an acute exacerbation. To reduce cardiac workload, which intervention should the nurse include in the client's plan of care?
- A. Assist with ambulation in the hallway
- B. Encourage active range of motion exercises
- C. Provide a bedside commode for toileting
- D. Teach to sleep in a side-laying position
Correct Answer: C
Rationale: Providing a bedside commode reduces the need for the client to walk to the bathroom, decreasing strain on the heart.
In truncus arteriosus, all the following are true EXCEPT
- A. VSD is always present
- B. clinical manifestations are characterized by severe cyanosis and the degree of cyanosis are high
- C. both ventricles fail clinically
- D. cyanosis is usually mild
Correct Answer: B
Rationale: Cyanosis is usually mild initially in truncus arteriosus.
The following statements concerning acute gastroenteritis in childhood are correct:
- A. Intravenous fluid therapy is essential in severe cases
- B. Loperamide should be avoided
- C. The commonest causes of failure to thrive following an attack is persistent bacterial infection
- D. Septicaemia is a recognised feature of Salmonella gastroenteritis
Correct Answer: A
Rationale: Intravenous fluid therapy is critical in severe dehydration due to gastroenteritis. Loperamide is contraindicated in children due to risk of serious side effects. Persistent bacterial infection is not the commonest cause of failure to thrive, and septicaemia is rare in Salmonella gastroenteritis.
In the treatment of asthma, inhaled corticosteroids:
- A. Relieve acute symptoms
- B. Prevent long-term symptoms
- C. Cause airway constriction
- D. Are contraindicated in pregnancy
Correct Answer: B
Rationale: Inhaled corticosteroids are used in asthma management to prevent inflammation and control long-term symptoms, though they do not relieve acute attacks.