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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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

Correct Answer is A

Explanation

Choice A rationale

Breast cancer can occur in any part of the breast, but ductal breast cancer is most common. This statement is correct because the majority of breast cancers originate in the ducts that carry milk to the nipple. Ductal carcinoma in situ (DCIS) and invasive ductal carcinoma (IDC) are the most common types of breast cancer, accounting for about 80% of all cases.
Choice B rationale
Breastfeeding increases the risk of breast cancer in women over 40 years of age. This statement is incorrect. In fact, breastfeeding is known to reduce the risk of breast cancer. The longer a woman breastfeeds, the greater the protective effect. This is thought to be due to hormonal changes that occur during lactation, which may delay the return of menstrual periods and reduce a woman’s lifetime exposure to hormones like estrogen that can promote breast cancer cell growth.
Choice C rationale
Clients who have BRCA1 or BRCA2 gene changes have a decreased risk of breast cancer. This statement is incorrect. Mutations in the BRCA1 and BRCA2 genes significantly increase the risk of developing breast cancer. Women with these mutations have a 45-65% chance of developing breast cancer by age 70, compared to about 12% for women in the general population. These genes normally help repair DNA damage, but when they are mutated, they can lead to the development of cancer.
Choice D rationale
Clients should begin screening mammography annually by the age of 50 years old. This statement is partially correct but not entirely accurate. The American Cancer Society recommends that women with an average risk of breast cancer should start annual mammograms at age 45 and can switch to biennial screening at age 55. However, women should have the option to start screening as early as age 40 if they choose.

A. A room that is within view of the nurses’ station. B. A room with another nonsurgical client. C. A room in the ICU. D. A room with air exhaust directly to the outdoor environment.

Correct Answer is D

Explanation

Choice A rationale
A room that is within view of the nurses’ station is not suitable for a client with active tuberculosis. This placement does not provide the necessary isolation to prevent the spread of the infection to other patients and staff. Tuberculosis is an airborne disease, and the client needs to be in a room that minimizes the risk of airborne transmission.
Choice B rationale
A room with another nonsurgical client is also inappropriate for a client with active tuberculosis. Placing the client with another patient increases the risk of transmission of the infection. Tuberculosis requires strict airborne precautions, and the client should be in a private room with appropriate ventilation.
Choice C rationale
A room in the ICU is not necessary unless the client requires intensive care for other reasons. The primary concern for a client with active tuberculosis is to prevent the spread of the infection, which can be effectively managed in a regular medical-surgical unit with proper isolation measures.
Choice D rationale
A room with air exhaust directly to the outdoor environment is the correct choice. This type of room, often referred to as a negative pressure room, ensures that air from the room does not flow to other parts of the facility, thereby preventing the spread of infectious airborne particles. This setup is essential for managing clients with active tuberculosis.

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Naxlex Comprehensive Predictor Exams

A nurse is educating clients about breast cancer at a community health event. Which of the following statements should the nurse include in the training?

Correct Answer is A

Explanation

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?

Correct Answer is D

Explanation

A nurse is providing discharge instructions to the parent of a 10-year-old child following a cardiac catheterization. Which of the following instructions should the nurse include?

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?

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?

A nurse is assessing a client who has a pneumothorax with a chest tube in place For which of the following findings should the nurse notify the provider?

A nurse is providing teaching to a client who has atrial fibrillation and reports dizziness and palpitations. Which of the following should the nurse understand is the cause of these manifestations?

A nurse is reviewing the CBC findings for a female client who is receiving combination chemotherapy for breast cancer. Which of the following findings should the nurse report to the provider?

A nurse is caring for a school-age child who has leukemia. Exhibits Which of the following assessment findings should the nurse report to the provider? Select the 6 findings that should be reported to the provider.