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.
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Reviewing laboratory test results for low hemoglobin is important for monitoring anemia, which can be a side effect of radiation therapy. However, it is not the most immediate action to address the specific side effects of radiation therapy to the lung, such as xerostomia (dry mouth) and skin reactions.
Choice B rationale
Assessing the skin for erythema is important as radiation therapy can cause skin reactions, including redness and irritation. However, this action does not directly address the management of xerostomia, which is a common side effect of radiation therapy to the head and neck areas.
Choice C rationale
Monitoring the client for signs of fatigue is essential as fatigue is a common side effect of radiation therapy. However, this action does not specifically address the management of xerostomia, which requires targeted oral care.
Choice D rationale
Providing oral care to manage xerostomia is the correct action. Xerostomia, or dry mouth, is a common side effect of radiation therapy, especially when the head and neck are involved. Oral care helps to alleviate discomfort, prevent infections, and maintain oral health.
Correct Answer is C
Explanation
Choice A rationale
Take temperature weekly. This statement is incorrect. Clients with neutropenia should monitor their temperature daily, not weekly, because they are at high risk for infections. A fever can be an early sign of infection, and prompt detection is crucial for timely treatment.
Choice B rationale
Perform mild exercise, such as gardening. This statement is incorrect. While mild exercise can be beneficial, activities like gardening can expose neutropenic clients to soil and plants that may harbor bacteria and fungi, increasing the risk of infection.
Choice C rationale
Avoid crowds. This statement is correct. Neutropenic clients are highly susceptible to infections due to their weakened immune systems. Avoiding crowded places reduces the risk of exposure to pathogens that can cause infections.
Choice D rationale
Eat plenty of fresh fruits and vegetables. This statement is incorrect. While fresh fruits and vegetables are generally healthy, they can harbor bacteria and other pathogens that pose a risk for neutropenic individuals. It is often recommended that neutropenic clients eat cooked or canned fruits and vegetables instead.
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