A nurse on a cardiac care unit is caring for a preschooler.

Hospital Day 1, 17:38:

Medication Administration Record.

20:15:

Received 4-year-old child with an exacerbation of heart failure.

Family reports history of congenital mitral stenosis.

Breath sounds with wheezing noted in bilateral lower lobes.

Nonproductive cough noted.

Dyspnea with respiratory rate 30/min.

Oxygen at 2 L/min applied per nasal cannula.

Telemetry applied:

Sinus rhythm at rate 116/min.

Abdomen soft, nontender.

Bowel sounds positive in all 4 quadrants.

Lower extremities with 2+ edema noted.

Pedal pulses palpable bilaterally.

Peripheral saline lock intact to right forearm with no signs and symptoms of infection.

Weight 26 kg (44 lb).

Increase in dyspnea noted with orthopnea.

Nasal flaring with respiratory rate of 36/min. Lung sounds with wheezing noted throughout.

Lower extremity edema 3+ to bilateral lower extremities.

Extremities cool with decreased skin pigmentation noted.

Peripheral pulses weak bilaterally.

Jugular vein distention noted.

Provider notified.

Received prescription for additional dose of furosemide.

The client is at risk for developing:

Hypercyanotic spells.

Murmur.

Digitalis toxicity.

Dependent rubor.

Fever.

Carditis.

Answer and Explanation

Correct Answer : C

Choice A rationale
Hypercyanotic spells, also known as “tet spells,” are typically associated with Tetralogy of Fallot, a congenital heart defect. The child in this scenario has congenital mitral stenosis, not Tetralogy of Fallot, making hypercyanotic spells less likely.
Choice B rationale
A murmur is a sound made by turbulent blood flow within the heart. While the child may have a murmur due to congenital mitral stenosis, it is not a direct risk associated with the exacerbation of heart failure. The primary concern here is the risk of digitalis toxicity due to the administration of furosemide.
Choice C rationale
Digitalis toxicity is a significant risk for this child. Furosemide, a diuretic, can cause electrolyte imbalances, particularly hypokalemia, which increases the risk of digitalis toxicity. Symptoms of digitalis toxicity include nausea, vomiting, dizziness, and arrhythmias.
Choice D rationale
Dependent rubor is a reddish-blue discoloration of the extremities, typically associated with peripheral arterial disease. It is not directly related to heart failure or the administration of furosemide.
Choice E rationale
Fever is not a typical complication of heart failure or the administration of furosemide. It is more commonly associated with infections or inflammatory conditions.
Choice F rationale
Carditis, or inflammation of the heart, is not a direct risk associated with the exacerbation of heart failure or the administration of furosemide. The primary concern remains digitalis toxicity.

Nursing Test Bank

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Correct Answer is A

Explanation

Choice A rationale
Prostate cancer mortality is more than double for Black American males than for other groups. This is a significant consideration when creating a plan of care for prostate screening in high- risk populations. Black American males have a higher incidence and mortality rate of prostate cancer compared to other racial and ethnic groups. This disparity is attributed to a combination of genetic, socioeconomic, and healthcare access factors. Therefore, targeted screening and early detection efforts are crucial for this high-risk population to improve outcomes and reduce mortality rates.
Choice B rationale
Occupational toxic exposure among factory workers can increase the risk of various cancers, including prostate cancer. However, this is not the most important consideration when creating a plan of care for prostate screening in high-risk populations. While occupational exposure is a risk factor, it does not have the same level of impact on prostate cancer incidence and mortality as race and family history. Screening efforts should prioritize those with the highest risk, such as Black American males and individuals with a family history of prostate cancer.
Choice C rationale
Dietary factors can influence the risk of prostate cancer, but the impact is not as significant as other risk factors such as race and family history. While a healthy diet is important for overall health and may help reduce cancer risk, it is not the primary consideration for prostate screening in high-risk populations. Screening efforts should focus on those with the highest risk based on genetic and demographic factors, rather than dietary habits alone.
Choice D rationale
A computed tomography (CT) scan is not the best way to determine prostate cancer risk. The primary screening method for prostate cancer is the prostate-specific antigen (PSA) blood test, often combined with a digital rectal exam (DRE). CT scans are not typically used for initial screening but may be employed for further evaluation if there are abnormal findings on PSA or DRE. The focus should be on using established screening methods to identify high-risk individuals and provide early detection and intervention.

A. Chest pain and dyspnea. B. Seizures. C. Hematuria. D. Swelling of the extremities.

Correct Answer is B

Explanation

Choice A rationale
Chest pain and dyspnea are concerning symptoms but are not the most immediate manifestations to report in a client undergoing radiation therapy for brain cancer. These symptoms could be related to other conditions and require further evaluation.
Choice B rationale
Seizures are the most immediate manifestation to report because they indicate increased intracranial pressure or other neurological complications related to brain cancer and radiation therapy. Seizures require prompt medical intervention to prevent further complications.
Choice C rationale
Hematuria is a concerning symptom but is not the most immediate manifestation to report in this context. It could be related to other conditions and requires further evaluation.
Choice D rationale
Swelling of the extremities is a concerning symptom but is not the most immediate manifestation to report in this context. It could be related to other conditions and requires further evaluation.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is creating a plan of care for prostate screening in high-risk populations. Which of the following is an important consideration?

Correct Answer is A

Explanation

A nurse is caring for a client who has brain cancer and is undergoing radiation therapy. Which of the following manifestations should the nurse report immediately?

Correct Answer is B

Explanation

A nurse is providing teaching to a client who has neutropenia. Which of the following information should the nurse include in the teaching?

A nurse is teaching a client who has septic shock about the development of disseminated intravascular coagulation (DIC). Which of the following statements should the nurse make?

A nurse is assessing a client who has disseminated intravascular coagulation (DIC). Which of the following findings should the nurse expect?

A nurse is admitting a client who has active tuberculosis to a room on a medical-surgical unit. Which of the following room assignments should the nurse make for the client?

A nurse is caring for a client with a tracheostomy. The client’s partner has been taught to perform suctioning. Which of the following actions by the partner should indicate to the nurse a readiness for the client’s discharge?

A nurse is caring for a client who has chronic renal disease and is receiving therapy with epoetin alfa. Which of the following laboratory results should the nurse review for an indication of a therapeutic effect of the medication?