ATI RN
Pediatric Cardiovascular Nursing Questions Questions
Question 1 of 5
A nurse assesses a client who is recovering after a left-sided cardiac catheterization. Which assessment finding requires immediate intervention?
Correct Answer: C
Rationale: In this scenario, the correct answer is C) Slurred speech and confusion, which requires immediate intervention. This finding suggests a potential complication of the cardiac catheterization procedure, such as a stroke or embolism, which could be life-threatening. Option A) Urinary output less than intake is important but not as urgent as the neurological symptoms in option C. It may indicate potential kidney issues related to the procedure. Option B) Bruising at the insertion site is a common and expected finding post-catheterization, usually not requiring immediate intervention unless it is extensive, actively bleeding, or causing other complications. Option D) Discomfort in the left leg is also a common post-procedure finding and may be managed with pain medication and monitoring for signs of deep vein thrombosis, but it is not as urgent as the neurological symptoms in option C. Educationally, this question highlights the critical nature of assessing and prioritizing post-procedural complications in pediatric cardiovascular nursing. Nurses need to be able to recognize and respond promptly to signs of potential complications to ensure the best outcomes for their patients. This scenario emphasizes the importance of neurological assessment and quick decision-making in the post-catheterization care of pediatric patients.
Question 2 of 5
A nurse auscultated heart tones on an older adult client. Which action should the nurse take based on the heart tones heard?
Correct Answer: B
Rationale: In this scenario, the correct answer is B) Document the finding. Auscultating heart tones on an older adult client is a crucial nursing assessment skill. Documenting the finding is essential for maintaining accurate and thorough patient records, which aids in tracking changes in the client's condition over time and facilitates effective communication among healthcare team members. Administering a diuretic (option A) would not be appropriate based solely on auscultating heart tones. Diuretics are typically prescribed for conditions like heart failure or hypertension, but auscultation alone does not provide enough information to justify initiating diuretic therapy. Decreasing the IV flow rate (option C) is not indicated based solely on heart tone assessment. Adjusting IV flow rates should be guided by comprehensive patient assessment data, including factors like fluid status, medication compatibility, and the client's overall condition. Evaluating the client's medications (option D) is important in the broader context of patient care but is not directly linked to the immediate action needed after auscultating heart tones. While medication review is essential for assessing potential contributing factors to cardiovascular issues, it is not the most immediate or specific action following heart tone assessment. Educationally, this question highlights the importance of accurate documentation in nursing practice. It underscores the need for nurses to possess strong assessment skills, critical thinking abilities, and knowledge of appropriate interventions based on assessment findings. By documenting accurately, nurses contribute to the continuity of care and promote patient safety and quality outcomes.
Question 3 of 5
The nurse is caring for a school-age child who has had a cardiac catheterization. The child tells the nurse that the bandage is “too wet.” The nurse finds the bandage and bed soaked with blood. What is the priority nursing action?
Correct Answer: D
Rationale: If bleeding occurs, direct continuous pressure is applied 2.5 cm (1 inch) above the percutaneous skin site to localize pressure over the vessel puncture. Notifying a physician and applying a new bandage can be done after pressure is applied. The nurse can have someone else notify the physician while the pressure is being maintained. It is not a helpful intervention to place the girl in the Trendelenburg position. It would increase the drainage from the lower extremities.
Question 4 of 5
A nurse is teaching nursing students the physiology of congenital heart defects. Which defect results in decreased pulmonary blood flow?
Correct Answer: B
Rationale: Tetralogy of Fallot results in decreased blood flow to the lungs. The pulmonic stenosis increases the pressure in the right ventricle, causing the blood to go from right to left across the ventricular septal defect. Atrial and ventricular septal defects and patent ductus arteriosus result in increased pulmonary blood flow.
Question 5 of 5
An 8-year-old child is receiving digoxin (Lanoxin). The nurse should notify the practitioner and withhold the medication if the apical pulse is less than _____ beats/min.
Correct Answer: B
Rationale: In pediatric cardiovascular nursing, monitoring a child's response to digoxin therapy is crucial due to its narrow therapeutic index and potential toxicity. The correct answer is option B) 70 beats/min. This is because digoxin, a cardiac glycoside, works by increasing the force of the heart's contractions, but with toxicity, it can lead to bradycardia. An apical pulse below 70 beats/min in a child indicates bradycardia, which can be a sign of digoxin toxicity. Option A) 60 beats/min is too low for a child's normal pulse rate and would indicate a need for intervention or further assessment, but it is not the specific threshold for digoxin toxicity. Option C) 90 and D) 100 beats/min are within normal pediatric pulse ranges and would not necessarily indicate digoxin toxicity. Educationally, understanding the impact of digoxin on the pediatric cardiovascular system, the importance of monitoring vital signs, especially the pulse rate, and recognizing signs of toxicity are vital for nurses caring for pediatric patients on digoxin therapy. This knowledge ensures early detection of adverse effects, prompt intervention, and improved patient outcomes.