Nokea
What are THREE long-term complications that can occur after repair of coarctation of the aorta in an infant?
- A. Berry aneurysms
- B. Persistent systemic hypertension
- C. Re-coarctation
- D. All of the above
Correct Answer: D
Rationale: Long-term follow-up is necessary for patients who have undergone repair of coarctation due to risks of recurrence or complications.
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Fluids are restricted to 1,500 ml daily for a male client with acute kidney injury (AKI). He is frustrated and complaining of constant thirst, and the nurse discovers that the family is providing the client with additional fluids. Which intervention should the nurse implement?
- A. Remove all sources of liquids from the client's room
- B. Allow family to give client a measured amount of ice chips
- C. Restrict family visiting until the client's condition is stable
- D. Provide the client with oral swabs to moisten his mouth
Correct Answer: D
Rationale: Oral swabs can help alleviate thirst without increasing fluid intake, which is restricted in AKI.
A hospitalized client with chemotherapy-induced stomatitis complains of mouth pain. What is the best initial nursing action?
- A. Encourage frequent mouth care
- B. Cleanse the tongue and mouth with glycerin swabs
- C. Obtain a soft diet for the client
- D. Administer a topical analgesic per PRN protocol.
Correct Answer: D
Rationale: Administering a topical analgesic provides immediate pain relief, allowing the client to tolerate mouth care and other interventions.
The nurse is caring for a child who has undergone a cardiac catheterization. During recovery, the nurse notices the dressing is saturated with bright red blood. The nurse's first action is to:
- A. Call the interventional cardiologist
- B. Notify the cardiac catheterization laboratory that the child will be returning
- C. Apply a bulky pressure dressing over the present dressing
- D. Apply direct pressure 1 inch above the puncture site
Correct Answer: D
Rationale: Direct pressure above the puncture site helps control bleeding by localizing pressure over the vessel.
An emergency room nurse obtains the health history of a client. Which statement by the client should alert the nurse to the occurrence of heart failure?
- A. I get short of breath when I climb stairs.
- B. I see halos floating around my head.
- C. I have trouble remembering things.
- D. I have lost weight over the past month.
Correct Answer: A
Rationale: Shortness of breath, especially during exertion, is a classic symptom of heart failure due to the heart's inability to pump blood effectively.
The nurse is monitoring an infant with a congenital heart disease closely for signs of heart failure. Which early sign should the nurse be most concerned about?
- A. Pallor
- B. Cough
- C. Tachycardia
- D. Slow and shallow breathing
Correct Answer: C
Rationale: Tachycardia is an early sign of heart failure in infants because the heart attempts to compensate for decreased cardiac output by increasing the heart rate.