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Question 1 of 5

A six-month-old is receiving Lanoxin elixir (digoxin) following the repair of a VSD. Which finding should be reported to the physician?

Correct Answer: C

Rationale: A heart rate of 80 beats per minute in a six-month-old is low (normal range: 100-160 bpm) and may indicate digoxin toxicity or worsening cardiac function post-VSD repair. The other findings are within normal limits for an infant.

Question 2 of 5

The nurse is caring for a client with a history of atrial fibrillation. Which finding requires immediate intervention?

Correct Answer: C

Rationale: Dizziness and syncope in atrial fibrillation suggest hemodynamic instability, possibly from rapid ventricular response, requiring immediate intervention. Mild tachycardia, normal BP, and saturation are less urgent.

Question 3 of 5

The nurse is evaluating the laboratory value results of a client after a craniotomy for a pituitary tumor. Which values cause the nurse to suspect a diabetes insipidus complication?

Question Image

Correct Answer: A, B

Rationale: Diabetes insipidus causes dilute urine (low specific gravity,
A) and hypernatremia (158 mEq/L,
B) from excessive water loss. Potassium (
C), hemoglobin (
D), and chloride (E) are normal and unrelated.

Question 4 of 5

Following her surgery, a 5-year-old child will return to the pediatric unit with a long-arm cast. She experienced a supracondylar fracture of the humerus near the elbow. Which nursing action is most essential during the first 24 hours after surgery and cast application?

Correct Answer: D

Rationale: Neurovascular status of the extremity is of primary importance. The risk of circulatory impairment exists with any cast application, especially with fractures near the elbow.

Question 5 of 5

A 6-month-old infant has developmental delays. His weight falls below the 5th percentile when plotted on a growth chart. A diagnosis of failure to thrive is made. What behaviors might indicate the possibility of maternal deprivation?

Correct Answer: B

Rationale: Normal infant attachment behaviors include responding to touch and wanting to be held. Maternal deprivation behaviors include poor feeding, stiffening and refusal to eat, and inconsistencies in responsiveness. Attachment behavior includes maintaining eye contact. Maternal deprivation behaviors include displeasure with touch and physical contact.

Similar Questions

A female client has married recently. A month ago she visited her physician with complaints of burning on urination. She was given a prescription for trimethoprim-sulfamethoxazole (Bactrim) DS bid for 10 days. She was admitted through the emergency room on Saturday evening complaining of flank pain. Her temperature was 104°F. A preliminary urinalysis revealed 31 bacteria along with red and white blood cells Rankings blood cells in the urine. A preliminary diagnosis of pyelonephritis was made. During a nursing admission assessment, which statement by the client demonstrates a possible cause for pyelonephritis?
A client with a history of hyperparathyroidism is admitted with complaints of fatigue. The nurse should expect the client to have:
The client will be more comfortable and the results more accurate when the nurse prepares the client for Leopold's maneuvers by having her:
As the nurse assesses a male adolescent with chlamydia, the nurse determines that a sign of chlamydia is:
A male client is admitted to the medical-surgical unit from the emergency room with a diagnosis of acute pancreatitis. The nurse performs the admission nursing assessment. He is NPO with IV fluids infusing at 100 mL/hour. He is experiencing excruciating abdominal pain. Based on an analysis of these data, which nursing diagnosis would receive the highest priority?

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