ATI RN
Pediatric Cardiovascular Disorders Nursing Questions
Question 1 of 5
A male client complains of pain in his right calf, and the nurse determines that his calf is edematous and deep red. What intervention has the highest priority?
Correct Answer: A
Rationale: The highest priority intervention in this scenario is option A) Tell the client to remain in bed. This presentation of pain, edema, and redness in the calf is indicative of a potential deep vein thrombosis (DVT). By advising the client to stay in bed, we aim to limit movement that could dislodge a blood clot, potentially causing a pulmonary embolism. This intervention is crucial to prevent a life-threatening complication. Option B) Apply warm compresses is not recommended in this case as heat can increase blood flow and potentially dislodge a clot, leading to adverse outcomes. Option C) Administer pain medication as prescribed may help alleviate the discomfort but does not address the underlying issue of a potential DVT. Option D) Encouraging the client to elevate the affected leg is generally beneficial for conditions like venous insufficiency but is not the most critical intervention when DVT is suspected. In an educational context, understanding the priority interventions for different conditions is vital for nurses to provide safe and effective care to patients. Recognizing the signs and symptoms of DVT and knowing the appropriate actions to take can prevent serious complications and improve patient outcomes.
Question 2 of 5
In assessing a client with ulcers on the lower extremity, which findings indicate that the ulcers are likely to be of venous, rather than arterial, origin?
Correct Answer: B
Rationale: In assessing a client with ulcers on the lower extremity, findings that indicate venous ulcers over arterial ulcers are irregular ulcer shapes and severe edema. Venous ulcers tend to have irregular shapes due to the underlying venous hypertension, while arterial ulcers are typically more uniform in shape. Severe edema is also more characteristic of venous insufficiency, as impaired venous return leads to fluid accumulation in the tissues. Option A, black ulcers and dependent rubor, are more indicative of arterial ulcers. Black ulcers suggest ischemia and necrosis, while dependent rubor is a sign of arterial insufficiency. Option C, absent pedal pulses and shiny skin, are also more indicative of arterial ulcers, as impaired arterial blood flow leads to diminished pulses and shiny, atrophic skin. Option D, hairless lower extremities and cool feet, can be seen in both arterial and venous insufficiency, but are not as specific to venous ulcers as irregular ulcer shapes and severe edema. Educationally, understanding the differences in presentation between venous and arterial ulcers is crucial for nurses caring for patients with cardiovascular disorders. Recognizing these differences can guide appropriate interventions and help prevent complications associated with mismanagement of these conditions.
Question 3 of 5
An older male client with long-standing lung disease is admitted to the medical unit for treatment of pulmonary infection. In assessing for signs of increasing hypoxia, which action should the nurse include? (select all that apply)
Correct Answer: B
Rationale: In this scenario, the correct action the nurse should include in assessing for signs of increasing hypoxia in an older male client with long-standing lung disease is to check for changes in mentation (Option B). This is because changes in mentation, such as confusion or altered level of consciousness, can be early indicators of worsening hypoxia in patients with lung disease. Monitoring dryness of mucous membranes (Option A) is not a reliable indicator of hypoxia in this case because it is more specific to hydration status rather than oxygenation. Observing the color of skin and nailbeds (Option C) is important for assessing oxygenation, but it is a later sign of hypoxia. Noting the appearance of jugular veins (Option D) is not directly related to assessing hypoxia in this context. Educationally, it is important for nurses to understand the various signs and symptoms of hypoxia in patients with respiratory conditions, as early recognition and intervention are crucial in preventing adverse outcomes. Checking for changes in mentation can provide valuable information about the client's oxygenation status and help guide appropriate nursing interventions.
Question 4 of 5
The nurse provides home care instructions to the parents of a child with heart failure regarding the procedure for administration of digoxin (Lanoxin). Which statement by the parent indicates a need for further instruction?
Correct Answer: A
Rationale: The correct answer is A) “If my child vomits after the medication administration, I will repeat the dose.” Rationale: A) This statement indicates a need for further instruction because if a child vomits after taking digoxin, repeating the dose can lead to overdosing, which can be harmful. It is crucial for parents to understand not to double dose without healthcare provider guidance. B) Mixing digoxin with food can alter its absorption, so it is correct not to mix it with food. C) Taking the child’s pulse before administering digoxin is essential as it helps monitor for signs of digoxin toxicity, so this statement is correct. D) Contacting the healthcare provider if more than one dose is missed is crucial to ensure proper management of the child's condition, making this statement correct. Educational Context: Parents need clear instructions on administering medications like digoxin to avoid potential harm. Understanding the importance of proper dosing, monitoring for side effects, and when to seek medical advice is crucial in managing pediatric cardiovascular disorders effectively. Reinforcing these key points can help parents confidently care for their child at home.
Question 5 of 5
A health care provider has prescribed oxygen as needed for an infant with heart failure. In which situation should the nurse administer the oxygen?
Correct Answer: A
Rationale: In pediatric cardiovascular disorders, the primary goal of administering oxygen to an infant with heart failure is to improve oxygenation and relieve respiratory distress. The correct answer is A) During sleep. This is because during sleep, an infant's oxygen demand may increase due to decreased respiratory drive and increased work of breathing, especially in the setting of heart failure. Providing oxygen during sleep helps meet this increased demand and ensures adequate oxygenation. Option B) When changing the infant's diapers is incorrect because this activity does not directly impact the infant's respiratory status or oxygenation needs. Option C) When the mother is holding the infant is also incorrect as the presence of the mother does not alter the infant's physiological need for oxygen. Option D) When drawing blood for electrolyte level testing is not the ideal time to administer oxygen as the focus during blood sampling should be on obtaining accurate laboratory results, and oxygen administration may not be necessary during this procedure. Educationally, understanding the appropriate timing for oxygen administration in infants with heart failure is crucial for nurses caring for pediatric patients with cardiovascular disorders. This knowledge ensures optimal management of respiratory distress and helps prevent complications associated with inadequate oxygenation in this vulnerable population. Nurses must be able to identify situations where oxygen supplementation is needed to provide safe and effective care for infants with heart failure.