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 C
Explanation
Choice A rationale
Bubbling of the water in the water seal chamber with exhalation. This statement is incorrect. Bubbling in the water seal chamber with exhalation can be normal and indicates that air is being expelled from the pleural space. It is not necessarily a cause for concern.
Choice B rationale
Eyelets are not visible. This statement is incorrect. The visibility of eyelets on the chest tube is not a standard indicator for notifying the provider. The focus should be on the function of the chest tube and the patient’s clinical status.
Choice C rationale
Movement of the trachea toward the unaffected side. This statement is correct. Tracheal deviation toward the unaffected side can indicate a tension pneumothorax, a life-threatening condition that requires immediate medical attention. It suggests that pressure is building up in the pleural space, compressing the lung and shifting the trachea.
Choice D rationale
Crepitus in the area above and surrounding the insertion site. This statement is incorrect. Crepitus, or subcutaneous emphysema, can occur when air leaks into the subcutaneous tissue around the chest tube insertion site. While it should be monitored, it is not necessarily an emergency requiring immediate notification of the provider.
Correct Answer is A
Explanation
Choice A rationale
Coronary arteries decrease in diameter leading to insufficient blood, oxygen, and nutrients reaching the heart muscle. This is correct because atherosclerosis, which is the buildup of plaque in the coronary arteries, causes the arteries to narrow. This narrowing reduces blood flow to the heart muscle, leading to ischemia and the manifestations of coronary artery disease, such as angina and myocardial infarction.
Choice B rationale
Manifestations occur due to dilation of coronary arteries with increased blood flow causing increased pressure. This is incorrect because the primary issue in coronary artery disease is the narrowing of the arteries, not their dilation. Increased blood flow and pressure are not typical causes of the manifestations of coronary artery disease.
Choice C rationale
Coronary arteries become more elastic causing the arteries to stretch as individuals age causing the heart not to receive enough oxygen. This is incorrect because the problem in coronary artery disease is not increased elasticity but rather the loss of elasticity and the buildup of plaque that narrows the arteries. As people age, the arteries tend to become less elastic, not more.
Choice D rationale
The heart and the coronary arteries weaken, leading to poor perfusion and resulting in angina. This is incorrect because the primary issue in coronary artery disease is the narrowing of the coronary arteries due to plaque buildup, not the weakening of the heart and arteries. While poor perfusion does result in angina, it is due to the narrowed arteries rather than weakened structures.
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