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The nurse is performing a physical assessment on a newborn. The nurse assessed 3+ brachial pulses, cold and pale feet, decreased capillary refill time in the feet, and warm and pink hands. Which cardiac disease process do these assessment findings support?
- A. Tetralogy of Fallot (TOF)
- B. Hypoplastic left heart syndrome
- C. Coarctation of the aorta (COA)
- D. Transposition of the great arteries
Correct Answer: C
Rationale: These findings suggest coarctation of the aorta, with reduced lower extremity perfusion due to aortic narrowing.
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The nurse receives a prescription to administer dopamine at 5 mcg/kg/min. The nurse has a bag labeled with dopamine 200 mg in 250 mL of D5W on hand. The client weighs 81.81 kg (179.98 lbs). How many mL/hr will the nurse administer?
Correct Answer: 31 mL/hr
Rationale: Calculation: 81.81 kg x 5 mcg/kg/min = 409.05 mcg/min x 60 = 24,543 mcg/hr = 24.543 mg/hr. Dopamine: 200 mg/250 mL = 0.8 mg/mL. 24.543 / 0.8 = 30.68 mL/hr, rounded to 31 mL/hr.
The nurse is teaching a class on substance use disorders. It would be correct for the nurse to characterize physical dependence as
- A. obsessive desire for the euphoric effects of a drug
- B. a need for a drug to avoid physical withdrawal symptoms
- C. severe effects that may be life-threatening
- D. unpleasant symptoms related to the absence of a drug
Correct Answer: B
Rationale: Physical dependence is defined as needing a drug to avoid withdrawal symptoms.
The nurse reviews a client's medical record taking prescribed isoniazid for pulmonary tuberculosis. Which laboratory data is most important to monitor?
- A. PT and PTT
- B. CBC
- C. BUN
- D. Liver enzymes
Correct Answer: D
Rationale: Isoniazid can cause hepatotoxicity, making liver enzyme monitoring critical.
The nurse in the emergency department (ED) is caring for a 10-year-old client.
Item 4 of 5
Nurses' Notes
1322: 10-year-old client and his parents report an 8-day history of a brownish-raised lesion over the back of his left leg. The parents report that the size of the rash has increased. The parents report returning from a one-week camping trip three weeks ago. The parents deny efficacy with over-the-counter antihistamine creams. The client's parents deny that the child has had a fever but has felt 'warm' occasionally and endorsed an intermittent headache. They report an area of firmness in the child's groin. On assessment, there was an erythematous, raised, nonpainful, oval patch on the back of his left leg. This was an enlargement of an inguinal lymph node. The child is alert and fully oriented and denies any pain. Peripheral pulses palpable 2+. No cyanosis or edema in the extremities. Lung sounds clear bilaterally. The parents report that the child did not receive the seasonal influenza vaccine. He currently takes a multivitamin for iron deficiency anemia and was hospitalized one year ago for an appendectomy. The parents state that the child’s sibling had influenza one month ago. Vital signs: T 98.8°F (37.1°C); HR 78 beats/min; RR 16 breaths/min; BP 110/76 mm Hg. SpO2 97% on room air.
Progress Notes
1401: The client was evaluated. The rash is localized, raised, and appears like a bullseye. The client has inguinal lymphadenopathy. The client's recent camping trip supports the probability of a vector-borne illness—specifically, Lyme disease.
The nurse reviews the physician's progress note and plans care for this client. For each potential intervention, click to specify whether the intervention is indicated or not indicated for the client.
- A. Obtain confirmatory testing via urine specimen
- B. Notify the local health department if confirmation testing comes back positive
- C. Request an order for antiviral medication
- D. Prepare the client for lumbar puncture
Correct Answer: B (indicated); A, C, D (not indicated)
Rationale: Notifying the health department is indicated for Lyme disease. Urine testing, antivirals, and lumbar puncture are not indicated for Lyme disease diagnosis or management.
The nurse in the emergency department (ED) is caring for a 10-year-old client.
Item 2 of 5
Nurses' Notes
1322: 10-year-old client and his parents report an 8-day history of a brownish-raised lesion over the back of his left leg. The parents report that the size of the rash has increased. The parents report returning from a one-week camping trip three weeks ago. The parents deny efficacy with over-the-counter antihistamine creams. The client's parents deny that the child has had a fever but has felt 'warm' occasionally and endorsed an intermittent headache. They report an area of firmness in the child's groin. On assessment, there was an erythematous, raised, nonpainful, oval patch on the back of his left leg. This was an enlargement of an inguinal lymph node. The child is alert and fully oriented and denies any pain. Peripheral pulses palpable 2+. No cyanosis or edema in the extremities. Lung sounds clear bilaterally. The parents report that the child did not receive the seasonal influenza vaccine. He currently takes a multivitamin for iron deficiency anemia and was hospitalized one year ago for an appendectomy. The parents state that the child’s sibling had influenza one month ago. Vital signs: T 98.8°F (37.1°C); HR 78 beats/min; RR 16 breaths/min; BP 110/76 mm Hg. SpO2 97% on room air.
The nurse considers if the client may have an infection caused by a tick. Click to specify if the features are consistent with the disease process of Rocky Mountain spotted fever (RMSF) or Lyme Disease.
- A. Fever
- B. Petechial rash that becomes diffuse
- C. Erythema migrans (bullseye rash)
- D. Myalgia
- E. Causative agent Rickettsia rickettsii
- F. Causative agent Borrelia burgdorferi
Correct Answer: C (Lyme Disease), F (Lyme Disease)
Rationale: The bullseye rash and Borrelia burgdorferi are specific to Lyme disease. Fever and myalgia can occur in both RMSF and Lyme disease, but the petechial rash and Rickettsia rickettsii are specific to RMSF.