Nokea
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.
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A 3-month-old infant has a hypercyanotic spell. What should be the nurses first action?
- A. Assess for neurologic defects.
- B. Prepare the family for imminent death.
- C. Begin cardiopulmonary resuscitation.
- D. Place the child in the kneechest position.
Correct Answer: D
Rationale: Placing the infant in the knee-chest position increases systemic vascular resistance, reducing the hypercyanotic spell. Oxygen and morphine may follow, but this is the first action. Neurologic defects, CPR, or preparing for death are inappropriate initial responses.
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.
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.
A 2-year-old child is receiving digoxin (Lanoxin). The nurse should notify the practitioner and withhold the medication if the apical pulse is less than which rate?
- A. 60 beats/min
- B. 90 beats/min
- C. 100 beats/min
- D. 120 beats/min
Correct Answer: B
Rationale: For infants and young children, digoxin is withheld if the 1-minute apical pulse is below 90 beats/min to prevent toxicity. A rate of 60 is the adult threshold, and 100-120 beats/min are acceptable for administration.
The parents of a young child with heart failure (HF) tell the nurse that they are nervous about giving digoxin. The nurses response should be based on which knowledge?
- A. It is a safe, frequently used drug.
- B. Parents lack the expertise necessary to administer digoxin.
- C. It is difficult to either overmedicate or undermedicate with digoxin.
- D. Parents need to learn specific, important guidelines for administration of digoxin.
Correct Answer: D
Rationale: Digoxin?s narrow therapeutic range requires parents to learn specific guidelines for safe administration and monitoring to prevent toxicity. It?s not inherently safe, parents can be taught, and over- or undermedication is a risk without proper guidance.