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.

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Correct Answer is D

Explanation

Choice A rationale
The client has an increased risk for bleeding. Cisplatin is a chemotherapy drug that can cause myelosuppression, leading to a decrease in platelets (thrombocytopenia). However, the client’s platelet count is 170,000/mm³, which is within the normal range (150,000-450,000/mm³).
Therefore, the client does not have an increased risk for bleeding based on the current CBC results.
Choice B rationale
The client should receive an erythropoiesis stimulating agent. Cisplatin can cause anemia due to myelosuppression, which would be indicated by a low hemoglobin (Hgb) and hematocrit (Hct). However, the client’s Hgb is 12.1 g/dL and Hct is 36.5%, both of which are within normal limits (Hgb: 12-16 g/dL for females, Hct: 36-48% for females). Therefore, there is no immediate need for an erythropoiesis stimulating agent based on the current CBC results.
Choice C rationale
The client should receive a diet with increased protein. While a high-protein diet can be beneficial for cancer patients to help maintain muscle mass and support recovery, the CBC results do not indicate a specific need for increased protein intake. The client’s albumin level is 4.5 g/dL, which is within the normal range (3.5-5.0 g/dL), indicating adequate protein status.
Choice D rationale
The client has an increased risk of infection. Cisplatin can cause neutropenia, a condition characterized by a low white blood cell (WBC) count, which increases the risk of infection. The client’s WBC count is 1,400/mm³, which is significantly below the normal range (4,000- 11,000/mm³). This indicates severe neutropenia, putting the client at a high risk for infections. Therefore, it is crucial for the nurse to consider infection prevention measures for this client.

A. Urinary output. B. Pain level. C. Chest tube drainage. D. Arterial blood gases assessment.

Correct Answer is D

Explanation

Choice A rationale
Urinary output is an important postoperative assessment, but it is not the highest priority for a client who has undergone a thoracotomy and lobectomy. Monitoring urinary output helps assess kidney function and fluid balance, but it does not directly address the respiratory status, which is critical in this case. The primary concern after thoracotomy and lobectomy is ensuring adequate oxygenation and ventilation, as the surgery directly impacts the lungs and respiratory function.
Choice B rationale

Pain level is a significant postoperative assessment, as effective pain management is crucial for recovery. However, it is not the highest priority in this scenario. While managing pain is essential to prevent complications such as atelectasis (collapse of part of the lung) due to shallow breathing, the immediate focus should be on assessing and maintaining adequate respiratory function. Pain management can be addressed once the client’s respiratory status is stabilized.
Choice C rationale
Chest tube drainage is a critical postoperative assessment for clients who have undergone thoracotomy and lobectomy. Monitoring chest tube output helps detect complications such as bleeding or pneumothorax (air in the pleural space). However, it is not the highest priority compared to arterial blood gases assessment. While chest tube drainage provides valuable information about the client’s condition, arterial blood gases assessment directly measures the client’s oxygenation and ventilation status, which is paramount in the immediate postoperative period.
Choice D rationale
Arterial blood gases (ABG) assessment is the highest priority for a client who is postoperative following a thoracotomy and lobectomy. ABG analysis provides crucial information about the client’s oxygenation, ventilation, and acid-base balance. This assessment helps detect hypoxemia (low blood oxygen levels), hypercapnia (elevated carbon dioxide levels), and respiratory acidosis, which are critical concerns after lung surgery. Ensuring adequate oxygenation and ventilation is the top priority to prevent respiratory complications and support the client’s recovery.

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is receiving cisplatin for treatment of ovarian cancer. The client’s most recent complete blood count (CBC) is shown in the table below. It is important for the nurse to consider which of the following for the client?

Correct Answer is D

Explanation

A nurse in the post-anesthesia care unit is caring for a client who is postoperative following a thoracotomy and lobectomy. Which of the following postoperative assessments should the nurse give highest priority to?

Correct Answer is D

Explanation

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