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While looking through the chart of an infant with a congenital heart defect (CHD) of decreased pulmonary blood flow, the nurse would expect which laboratory finding?
- A. Decreased platelet count
- B. Decreased ferritin level
- C. Respiratory alkalosis
- D. Polycythemia
Correct Answer: D
Rationale: Polycythemia is often seen in infants with congenital heart defects that cause decreased pulmonary blood flow, as the body produces more red blood cells to compensate for low oxygen levels.
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A client with acquired immunodeficiency syndrome (AIDS) has impaired gas exchange from a respiratory infection. Which assessment finding warrants immediate intervention by the nurse?
- A. Elevated temperature
- B. Generalized weakness
- C. Diminished lung sounds
- D. Pain when swallowing
Correct Answer: D
Rationale: Pain when swallowing could indicate an opportunistic infection such as candidiasis, which requires prompt treatment.
Which vaccines must be delayed for 11 months after the administration of gamma globulin? (Select all that apply.)
- A. Diphtheria, tetanus, and pertussis
- B. Hepatitis B
- C. Inactivated polio virus
- D. Measles, mumps, and rubella
Correct Answer: D
Rationale: Live virus vaccines (MMR and Varicella) should be delayed for 11 months after gamma globulin infusion because the passive antibodies can interfere with vaccine efficacy.
A health care provider has prescribed oxygen as needed for an infant with heart failure. In which situation should the nurse administer the oxygen?
- A. During sleep
- B. When changing the infant’s diapers
- C. When the mother is holding the infant
- D. When drawing blood for electrolyte level testing
Correct Answer: A
Rationale: Administering oxygen during sleep can help ensure the infant maintains adequate oxygenation, especially since infants with heart failure may have compromised respiratory function.
The most common coronary artery anomaly in Tetralogy of Fallot is
- A. Left anterior descending artery from right aortic sinus
- B. Single coronary artery from right aortic sinus
- C. Single coronary artery from left aortic sinus
- D. Left circumflex coronary artery from right aortic sinus
Correct Answer: A
Rationale: The most common coronary artery anomaly in Tetralogy of Fallot is the left anterior descending artery arising from the right aortic sinus.
Recurrent headaches in childhood are seen with:
- A. Tension headaches
- B. Migraine
- C. Sinusitis
- D. Hypermetropia
Correct Answer: B
Rationale: The correct answer is B because migraine is a common cause of recurrent headaches in children. The other options (a, c, d, e) are less common or present differently.