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.
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
A weight increase from 120 pounds to 122 pounds over 3 days is within the normal fluctuation range.
Choice B rationale:
A serum potassium level of 3.0 mEq/L after 1 week of therapy is concerning because it’s below the normal range (3.5-5.0 mEq/L)171819. This could indicate hypokalemia, which can cause serious complications if left untreated.
Choice C rationale:
A palpable liver edge 2 cm below the ribs on the right side could suggest an abnormality such as an enlarged liver.
Choice D rationale:
The presence of 1+ to 2+ edema in the feet and ankles could indicate conditions like heart failure or venous insufficiency.
So, the correct answer is Choice B, after analyzing all choices.
Correct Answer is B
Explanation
Choice A rationale:
ST segment changes on an ECG are not typically associated with chronic constrictive pericarditis.
Choice B rationale:
Jugular venous distention (JVD) is a common sign of chronic constrictive pericarditis. If JVD is not present, it may indicate that the therapies are effective.
Choice C rationale:
While the sedimentation rate can indicate inflammation, it is not specific to chronic constrictive pericarditis.
Choice D rationale:
The presence of a paradoxical pulse is not typically associated with chronic constrictive pericarditis.
So, the correct answer is B, after analyzing all choices.
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