Question 5461)
A 6-year-old child with tetralogy of Fallot is being admitted for surgery. What is
most important to teach the child during the preoperative period?
A. Strict hand washing technique
B. How to cough and deep breathe
C. The importance of drinking plenty of fluids
D. Positions of comfort
Answer: B
Explanation: The child will have to learn to cough and deep breathe postoperatively. Studies demonstrate that
preoperative teaching makes it easier for the client to perform coughing and deep breathing exercises in the
postoperative period. The nurses will do strict hand washing, not the client. Fluids will likely be restricted
postoperatively. It is important to teach the client about positions of comfort, but it is more important to teach the
child how to deep breathe and cough.
Question 5462)
A 6-year-old with tetralogy of Fallot has open heart surgery. The septal defect was
closed, and the pulmonic valve was replaced. When the child returns to the unit, he has oxygen,
IVs, and closed chest drainage. How should the nurse position the chest drainage system?
A. Above the level of the bed
B. At the level of the heart
C. Below the level of the bed
D. Alternating above and below the bed every two hours
Answer: C
Explanation: Chest bottles are always positioned below bed level to prevent the reflux of material into the chest
cavity.
Question 5463)
A parent brings a 3-week-old infant to the clinic. The parent states that the baby
does not eat very well. She takes 45 cc of formula in 45 minutes and gets “tired and sweaty”
when eating. The nurse observes the baby sleeping in the parent’s arms. Her color is pink, and the
child is breathing without difficulty. What is the best response for the nurse to make?
A. “It’s normal for an infant to get tired while feeding. That will go away as the child gets older.”
B. “It’s normal for an infant to get tired while feeding. You could try feeding the baby smaller amounts of formula
more frequently.”
C. “This could be a sign of a health problem. Does your baby’s skin color change while eating?”
D. “This could be a sign of a health problem. How does your baby’s behavior compare with your other children when
they were that age?”
Answer: C
Explanation: Activity intolerance related to feeding is often a key sign of a serious cardiac problem in an infant.
Taking only 45 cc of formula in 45 minutes at 3 weeks of age probably indicates difficulty sucking. This is definitely
not normal. The fact that the infant’s color is pink at rest does not tell you what happens during exertion, such as
with eating. Asking about skin color during feeding is a good first question to ask. Answers 1 and 2 are incorrect
because they interpret the infant’s behavior as normal, which it is not. Answer 4 is not correct. It does identify the
behavior as abnormal but suggests comparing it to the child’s siblings. This is not the appropriate question to ask to
get the most information.
Question 5464)
The nurse is explaining cardiac catheterization to the parents of a child. The nurse
explains to the parents that information about which of the following can be obtained during
cardiac catheterization?
A. Oxygen levels in the chambers of the heart
B. Pulmonary vascularization
C. Presence of abdominal aortic aneurysm
D. Activity tolerance
Answer: A
Explanation: The catheter is passed into the chambers of the heart, and oxygen levels can be measured. The
cardiac catheter does not assess pulmonary vascularization. Coronary arteries can be visualized, however. An
abdominal aortic aneurysm is diagnosed with an arteriogram, not a cardiac catheterization. A cardiac
catheterization gives information about the heart structures but does not give information about activity
tolerance.
Question 5465)
The nurse is caring for a toddler who is six hours post cardiac catheterization. The
nurse is administering antibiotics. The child’s mother asks why the child needs to have antibiotics.
The nurse’s response should indicate that antibiotics are given to the client to prevent which type
of infection?
A. Urinary tract infection
B. Pneumonia
C. Otitis media
D. Endocarditis
Answer: D
Explanation: During a cardiac catheterization, a catheter is inserted into the heart; therefore, the infection that
the client is most at risk for is endocarditis. Urinary tract infection, pneumonia, and otitis media are not related to
a client undergoing a cardiac catheterization.
Question 5466)
The nurse is caring for a toddler with a cardiac defect who has had several
episodes of congestive heart failure in the past few months. Which data would be the most useful
to the nurse in assessing the child’s current congestive heart failure?
A. The degree of clubbing of the child’s fingers and toes
B. Amount of fluid and food intake
C. Recent fluctuations in weight
D. The degree of sacral edema
Answer: C
Explanation: Weight is the best indicator of fluid balance. Congestive heart failure causes fluid retention. Sacral
edema is positionally dependent. Weight will give a better indication of the child’s status. Clubbing of the fingers
and toes is an indication of chronic hypoxemia, not the status of his current congestive heart failure. Fluid and
food intake is a general indicator of his status and is not particularly related to his current congestive heart failure.
Question 5467)
A child with a cyanotic heart defect has an elevated hematocrit. What is the most
likely cause of the elevated hematocrit?
A. Chronic infection
B. Recent dehydration
C. Increased cardiac output
D. Chronic oxygen deficiency
Answer: D
Explanation: The body tries to compensate for chronic oxygen deficiency by making additional red cells to transport
oxygen. The additional red cells increase the hematocrit, which is the percentage of blood that is red blood cells.
Chronic infection can cause anaemia. Recent dehydration will cause an elevated hematocrit because there is less
fluid in the blood. However, there is no indication that the child is dehydrated, and we are told that he has a
cyanotic heart defect, which makes him chronically hypoxic. Therefore, answer 4 is better than answer 2. Answer
3, increased cardiac output, is also incorrect. Increased cardiac output does not cause an elevated hematocrit.
Question 5468)
The nurse is administering the daily digoxin dose of 0.035 mg to a 10-month-old
child. Before administering the dose, the nurse takes the child’s apical pulse, and it is 85. Which
of the following interpretations of these data is most accurate?
A. The child has just awakened, and the heart action is slowest in the morning.
B. This is a normal rate for a 10-month-old child.
C. The child may be going into heart block due to digoxin toxicity
D. The child’s potassium level needs to be evaluated.
Answer: C
Explanation: A pulse below 100 in a 10-month-old child who is taking digoxin most likely indicates digoxin toxicity.
The nurse should withhold the medication and notify the physician. The normal pulse for this age is about 120 or a
little more at rest. The pulse rate does not tell us that the child needs to have his/her potassium level checked. If
the child is also taking Lasix or another potassium-depleting diuretic, then the potassium should be checked.
Question 5469)
The nurse is discussing dietary needs of a child with a serious heart defect. The
child is being treated with digoxin and hydrochlorothiazide (Hydrodiuril). The nurse should stress
the importance of giving the child which of the following foods?
A. Cheese and ice cream
B. Finger foods such as hot dogs
C. Apricots and bananas
D. Four glasses of whole milk per day
Answer: C
Explanation: The child should be on a sodium-restricted diet with high-potassium foods because he is taking
Hydrodiuril, a potassium-depleting diuretic. Apricots and bananas are low in sodium and high in potassium. Cheese
and ice cream are high in sodium. Hot dogs are high in sodium. Whole milk is high in sodium. Not only is potassium
needed, but excessive sodium should also be avoided because those with severe heart defects are prone to fluid
retention.
Question 5470)
A child with a cyanotic heart defect has a hypoxic episode. What should the nurse
do for the child at this time?
A. Administer PRN oxygen and position the child in the squat position
B. Position the child side-lying and give the ordered morphine
C. Ask the parents to leave and start oxygen
D. Give oxygen and notify the physician
Answer: A
Explanation: The knee-chest or squat position increases intra-abdominal pressure and increases blood flow to the
lungs. Oxygen is also indicated because the child is hypoxic. Positioning on the side is not appropriate because it
will not improve the blood flow to the lungs. There is no need to ask the parents to leave. In fact, they need to
know how to handle these episodes if they are not yet comfortable doing so. Children with cyanotic heart defects
have hypoxic episodes fairly regularly. Positioning in the squat position is more important at this time than
notifying the physician.
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