ATI LPN
Wong's Essentials of Pediatric Nursing 11th Edition Test Bank
Chapter 23 : The Child with Cardiovascular Dysfunction Questions
Question 1 of 5
After returning from cardiac catheterization, the nurse monitors the childs vital signs. The heart rate should be counted for how many seconds?
Correct Answer: C
Rationale: Counting the heart rate for 60 seconds ensures accurate detection of arrhythmias or bradycardia. Shorter durations (15 or 30 seconds) are insufficient, and 120 seconds is unnecessarily long for routine assessment.
Question 2 of 5
After returning from cardiac catheterization, the nurse determines that the pulse distal to the catheter insertion site is weaker. How should the nurse respond?
Correct Answer: C
Rationale: A weaker pulse post-catheterization is expected initially and should be documented as a baseline for monitoring. The pulse should strengthen over hours. Elevation, warm compresses, or immediate notification are unnecessary unless neurovascular changes occur.
Question 3 of 5
The nurse is caring for a school-age girl who has had a cardiac catheterization. The child tells the nurse that her bandage is too wet. The nurse finds the bandage and bed soaked with blood. What nursing action is most appropriate to institute initially?
Correct Answer: D
Rationale: Applying direct pressure 2.5 cm above the catheter site controls bleeding by compressing the vessel. Notification and rebandaging follow, but pressure is the priority. Trendelenburg position may increase bleeding and is not indicated.
Question 4 of 5
What statement best identifies the cause of heart failure (HF)?
Correct Answer: B
Rationale: Heart failure results from the heart?s inability to pump sufficient blood, often due to congenital defects causing increased volume or pressure. It?s not a primary disease, not typically inherited, and involves increased, not diminished, myocardial workload.
Question 5 of 5
The nurse finds that a 6-month-old infant has an apical pulse of 166 beats/min during sleep. What nursing intervention is most appropriate at this time?
Correct Answer: C
Rationale: A sleeping pulse over 160 beats/min suggests tachycardia, an early sign of heart failure due to sympathetic stimulation, requiring practitioner evaluation. Oxygen or positioning may be needed later, but reporting is the priority. Recording alone delays intervention.