Nokea
The nurse is caring for a child with persistent hypoxia secondary to a cardiac defect. The nurse recognizes the risk of cerebrovascular accidents (strokes) occurring. What strategy is an important objective to decrease this risk?
- A. Minimize seizures.
- B. Prevent dehydration.
- C. Promote cardiac output.
- D. Reduce energy expenditure.
Correct Answer: B
Rationale: Preventing dehydration reduces stroke risk in hypoxic children with polycythemia, as dehydration increases blood viscosity. Seizure control, cardiac output, and energy expenditure are important but don?t directly address stroke risk.
You may also like to solve these questions
What nutritional component should be altered in the infant with heart failure (HF)?
- A. Decrease in fats
- B. Increase in fluids
- C. Decrease in protein
- D. Increase in calories
Correct Answer: D
Rationale: Infants with heart failure need increased calories due to elevated metabolic rates from poor cardiac function. Fats and protein should be increased to meet caloric needs, and fluids are carefully monitored to avoid overload.
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.
After returning from cardiac catheterization, the nurse determines that the pulse distal to the catheter insertion site is weaker. How should the nurse respond?
- A. Elevate the affected extremity.
- B. Notify the practitioner of the observation.
- C. Record data on the assessment flow record.
- D. Apply warm compresses to the insertion site.
Correct Answer: C
Rationale: A weaker pulse post-catheterization is expected initially and should be documented as a baseline for monitoring. The pulse should strengthen over hours. Elevation, warm compresses, or immediate notification are unnecessary unless neurovascular changes occur.
A 6-year-old child is scheduled for a cardiac catheterization. What consideration is most important in planning preoperative teaching?
- A. Preoperative teaching should be directed at his parents because he is too young to understand.
- B. Preoperative teaching should be adapted to his level of development so that he can understand.
- C. Preoperative teaching should be done several days before the procedure so he will be prepared.
- D. Preoperative teaching should provide details about the actual procedures so he will know what to expect.
Correct Answer: B
Rationale: Teaching adapted to a 6-year-old?s developmental level ensures understanding and reduces anxiety. Parents benefit but the child needs tailored explanations. Detailed procedures are too complex for this age, and teaching close to the procedure time is sufficient.
The nurse is caring for a school-age girl who has had a cardiac catheterization. The child tells the nurse that her bandage is too wet. The nurse finds the bandage and bed soaked with blood. What nursing action is most appropriate to institute initially?
- A. Notify the physician.
- B. Place the child in Trendelenburg position.
- C. Apply a new bandage with more pressure.
- D. Apply direct pressure above the catheterization site.
Correct Answer: D
Rationale: Applying direct pressure 2.5 cm above the catheter site controls bleeding by compressing the vessel. Notification and rebandaging follow, but pressure is the priority. Trendelenburg position may increase bleeding and is not indicated.