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What should be the main focus of the nurse when presenting information?
- A. Pharmacological treatment
- B. Surgical interventions available
- C. Patient education
- D. Reduction of aerobic exercise
Correct Answer: C
Rationale: Patient education is the primary focus of a hypertension-prevention program to promote lifestyle changes and awareness.
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Which congenital cardiac defect(s) cause(s) increased pulmonary blood flow?
- A. Atrial septal defects (ASDs)
- B. Tetralogy of Fallot
- C. Dextroposition of aorta
- D. Patent ductus arteriosus
- E. Ventricular septal defects (VSDs)
Correct Answer: A,D,E
Rationale: ASDs, patent ductus arteriosus, and VSDs cause increased pulmonary blood flow due to left-to-right shunting.
Which statement by the father leads the nurse to determine he understood the instructions?
- A. If the baby turns blue, I will hold him against my shoulder with his knees bent up toward his chest.'
- B. If the baby turns blue, I will lay him down on a firm surface with his head lower than the rest of his body.'
- C. If the baby turns blue, I will immediately put the baby upright in an infant seat.'
- D. If the baby turns blue, I will put the baby in supine position with his head elevated.'
Correct Answer: A
Rationale: The knee-chest position during a hypercyanotic spell in tetralogy of Fallot increases venous return and reduces cyanosis.
Which assessment would lead the nurse to suspect that a newborn infant has a ventricular septal defect?
- A. A loud, harsh murmur with a systolic thrill
- B. Cyanosis when crying
- C. Blood pressure higher in the arms than in the legs
- D. A machinery-like murmur
Correct Answer: A
Rationale: A loud, harsh murmur with a systolic thrill is a hallmark sign of a ventricular septal defect in newborns.
What does the nurse recognize as a sign of digoxin toxicity?
- A. Restlessness
- B. Decreased respiratory rate
- C. Increased urinary output
- D. Vomiting
Correct Answer: D
Rationale: Vomiting is a common sign of digoxin toxicity, along with nausea, anorexia, and pulse irregularities.
Which is the most appropriate nursing action related to the administration of digoxin (Lanoxin) to an infant?
- A. Counting the apical rate for 30 seconds before administering the medication
- B. Withholding a dose if the apical heart rate is less than 100 beats/minute
- C. Repeating a dose if the child vomits within 30 minutes of the previous dose
- D. Checking respiratory rate and blood pressure before each dose
Correct Answer: B
Rationale: Withholding digoxin if the infant's heart rate is below 100 beats/minute prevents potential toxicity and ensures safety.