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

Nurses' Notes.

Hospital Day 1. 1738: 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 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 20 kg (44 lb). 2015: 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 bilateral.

Jugular vein distention noted.

Provider notified.

Received prescription for additional dose of IV furosemide.

Medication Administration Record.

Hospital Day 1: Furosemide 40 mg IV every 6 hr. Administered at 1755.

Give digoxin 250 mcg IV now.

Administered at 1800.

Hospital Day 2: Give digoxin 125 mcg 12 hr after initial dose.

Administered at 0608.

Give digoxin 125 mcg 12 hr after second dose.

Administered at 1804.

Furosemide 10 mg IV now.

Administered at 2020.

Vital Signs.

Hospital Day 1. 1738: Temperature: 36.7°C (98.0°F). Pulse rate: 114/min.

Respiratory rate: 30/min.

Blood pressure: 92/65 mm Hg. Oxygen saturation: 90%. 2015: Temperature: 36.9°C (98.4°F). Pulse rate: 120/min.

Respiratory rate: 36/min.

Blood pressure: 86/54 mmHg.

Oxygen saturation: 86% room air.
select words from the choices below to fill in each blank in the following sentence. The client is at risk for developing Target 1? and Target 2?.

Dependent rubor.

Digitalis toxicity.

Carditis.

Hypercyanotic spells.

Hypokalemia.

Fever.

Hypertension.

Answer and Explanation

Correct Answer : B,E

Choice A rationale:

Dependent rubor refers to redness of the skin that occurs when the leg is in a dependent (hanging down) position. It is often associated with peripheral artery disease. However, the child’s symptoms do not indicate this condition.

Choice B rationale:

Digitalis toxicity can occur as a result of high levels of the drug digoxin. Symptoms can include nausea, vomiting, weakness, and vision changes. Given that the child has been administered digoxin, there is a risk for this condition.

Choice C rationale:

Carditis is inflammation of the heart or its surroundings. It is usually caused by bacterial or viral infections. The child’s symptoms do not suggest an infection, making this choice less likely.

Choice D rationale:

Hypercyanotic spells, also known as “tet spells,” are associated with Tetralogy of Fallot, a specific congenital heart defect. The child has a history of congenital mitral stenosis, not Tetralogy of Fallot, making this choice less likely.

Choice E rationale:

Hypokalemia, or low potassium levels, can occur as a side effect of taking diuretics like furosemide. Given that the child has been administered furosemide, there is a risk for this condition.

Choice F rationale:

Fever is usually a response to infection or inflammation. The child’s symptoms do not suggest an infection or inflammation, making this choice less likely.

Choice G rationale:

Hypertension, or high blood pressure, is not indicated in the child’s symptoms or history. The child’s blood pressure readings are within normal range, making this choice less likely.

Choice H rationale:

A murmur is a sound that can be heard when listening to the heart with a stethoscope. It is often caused by turbulent blood flow through the heart. The child’s notes do not mention a murmur, making this choice less likely.

So, the correct answer is, the child is at risk for developing Digitalis toxicity and Hypokalemia. .

Nursing Test Bank

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Correct Answer is ["A","B","C"]

Explanation

Choice A rationale:

Obtaining blood cultures x 3 is anticipated for the client. This is because the adolescent’s symptoms such as fever, shortness of breath, and petechiae could indicate a bacterial infection, possibly endocarditis, which is a risk for individuals with a history of rheumatic fever and cardiac valve damage. Blood cultures would help identify the causative bacteria.

Choice B rationale:

Administering antibiotic therapy is anticipated for the client. The adolescent’s symptoms suggest a possible bacterial infection, which could have been introduced during the recent dental work. Antibiotics would help eliminate the bacteria and prevent further complications.

Choice C rationale:

Obtaining an echocardiogram is anticipated for the client. Given the adolescent’s history of rheumatic fever and cardiac valve damage, and current symptoms like shortness of breath and chest pain, an echocardiogram would help assess the condition of the heart valves and detect any abnormalities.

Choice D rationale:

Restricting dental hygiene is contraindicated for the client. Good oral hygiene is important, especially for individuals with a history of rheumatic fever and cardiac valve damage, as it helps prevent oral infections that could potentially spread to the heart.

Choice E rationale:

Performing a strenuous exercise regimen twice daily is contraindicated for the client. The adolescent is currently experiencing symptoms like shortness of breath and chest pain, which could be exacerbated by strenuous exercise. It’s important to avoid overexertion until the adolescent’s condition stabilizes.

So, the correct answer is, after analyzing all choices, Choices A, B, and C are anticipated for the client, while Choices D and E are contraindicated. .

A. "Did you take any Tylenol today?". B. "Have there been recent stressful events in your life?". C. "Have you recently taken any cocaine or crack?". D. "Have you eaten any salty foods lately?". .

Correct Answer is C

Explanation

Choice A rationale:

Tylenol, or acetaminophen, is a common over-the-counter medication used to reduce fevers and manage mild aches and pains. It does not directly affect blood pressure.

Choice B rationale:

While stress can cause temporary spikes in blood pressure, it’s not clear whether stress can cause long-term increases in blood pressure34.

Choice C rationale:

Cocaine or crack use can cause a significant and dangerous increase in blood pressure. Given the patient’s history of drug abuse and the current high blood pressure reading, this is a critical question to ask.

Choice D rationale:

Eating salty foods can contribute to high blood pressure over time, but it’s unlikely to cause an immediate severe increase in blood pressure.

So, the correct answer is Choice C, after analyzing all choices. .

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["A","B","C"]

Explanation

A patient with a history of hypertension arrives in the emergency department with a blood pressure (BP) reading of 213/126 mm Hg. The patient has a history of drug abuse. Which of the following initial questions posed by the nurse is MOST appropriate?.

Correct Answer is C

Explanation

A nurse is supervising a new graduate who is providing discharge teaching to a patient diagnosed with hypertension. While teaching a patient about their newly prescribed diuretic (furosemide), which of the following statements made by the new graduate requires correction by the supervising nurse?.

The nurse is admitting a patient who has chest pain. Which assessment data suggest that the pain may be from an acute myocardial infarction?.

The nurse is providing teaching about the patient's laboratory values that increase the risk for coronary artery disease (CAD). Which of the following values should the nurse prioritize?.

A patient is admitted to the emergency department and diagnosed as having an ST-segment-elevation myocardial infarction (STEMI). Which question would the nurse ask to determine whether the patient is a candidate for thrombolytic therapy?.

A patient who has recently had an acute myocardial infarction (AMI) ambulates in the hospital hallway. Which data would indicate to the nurse that the patient should stop and rest?.

A patient who has heart failure recently started taking digoxin in addition to furosemide and captopril. Which finding by the home health nurse is a priority to communicate to the health care provider?.

The nurse is caring for a patient with mitral regurgitation. Where would the nurse listen to best hear a murmur typical of mitral regurgitation?.

Which action by the nurse will determine if therapies ordered for a patient with chronic constrictive pericarditis are effective?