Nokea
The nurse finds that a 6-month-old infant has an apical pulse of 166 beats/min during sleep. What nursing intervention is most appropriate at this time?
- A. Administer oxygen.
- B. Record data on the nurses notes.
- C. Report data to the practitioner.
- D. Place the child in the high Fowler position.
Correct Answer: C
Rationale: A sleeping pulse over 160 beats/min suggests tachycardia, an early sign of heart failure due to sympathetic stimulation, requiring practitioner evaluation. Oxygen or positioning may be needed later, but reporting is the priority. Recording alone delays intervention.
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Decreasing the demands on the heart is a priority in care for the infant with heart failure (HF). In evaluating the infants status, which finding is indicative of achieving this goal?
- A. Irritability when awake
- B. Capillary refill of more than 5 seconds
- C. Appropriate weight gain for age 18
- D. Positioned in high Fowler position to maintain oxygen saturation at 90%
Correct Answer: C
Rationale: Appropriate weight gain indicates successful feeding and reduced caloric loss, reflecting decreased cardiac demand. Irritability and prolonged capillary refill suggest ongoing HF, and high Fowler positioning aids breathing but doesn?t confirm reduced cardiac strain.
What clinical manifestation is a common sign of digoxin toxicity?
- A. Seizures
- B. Vomiting
- C. Bradypnea
- D. Tachycardia
Correct Answer: B
Rationale: Vomiting, unrelated to feedings, is a common sign of digoxin toxicity due to its narrow therapeutic range. Seizures are not associated, bradycardia (not bradypnea or tachycardia) may occur, but vomiting is a key indicator.
After returning from cardiac catheterization, the nurse monitors the childs vital signs. The heart rate should be counted for how many seconds?
- A. 15
- B. 30
- C. 60
- D. 120
Correct Answer: C
Rationale: Counting the heart rate for 60 seconds ensures accurate detection of arrhythmias or bradycardia. Shorter durations (15 or 30 seconds) are insufficient, and 120 seconds is unnecessarily long for routine assessment.
What blood flow pattern occurs in a ventricular septal defect?
- A. Mixed blood flow
- B. Increased pulmonary blood flow
- C. Decreased pulmonary blood flow
- D. Obstruction to blood flow from ventricles
Correct Answer: B
Rationale: A ventricular septal defect allows blood to shunt from the high-pressure left ventricle to the lower-pressure right ventricle, increasing pulmonary blood flow. It?s a one-way shunt, not mixed flow, doesn?t obstruct ventricular outflow, and isn?t associated with decreased flow.
What drug is an angiotensin-converting enzyme (ACE) inhibitor?
- A. Furosemide (Lasix)
- B. Captopril (Capoten)
- C. Chlorothiazide (Diuril)
- D. Spironolactone (Aldactone)
Correct Answer: B
Rationale: Captopril is an ACE inhibitor used in heart failure management. Furosemide is a loop diuretic, chlorothiazide acts on distal tubules, and spironolactone is a potassium-sparing diuretic, none of which are ACE inhibitors.