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.

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.

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.

Correct Answer: B

Rationale: In pediatric cardiovascular nursing, understanding the rationale behind dietary recommendations for children on specific medications like furosemide (Lasix) is crucial. The correct answer is option B) Potassium. Explanation of why Potassium is right: Furosemide is a loop diuretic that promotes the excretion of water and electrolytes, including potassium. Potassium depletion can be a side effect of furosemide use. Therefore, it is essential to consume potassium-rich foods like bananas, oranges, and leafy vegetables to replenish potassium levels and prevent hypokalemia, which can lead to adverse cardiac effects. Explanation of why others are wrong: A) Chlorides: While furosemide may affect chloride levels, the primary concern with furosemide use in this context is potassium depletion. C) Sodium: Furosemide actually promotes the excretion of sodium, so increasing sodium intake would not address the potential electrolyte imbalance caused by the medication. D) Vitamins: While vitamins are essential for overall health, the specific concern with furosemide use in this case is potassium depletion, not vitamin deficiency. Educational context: Educating families on the importance of potassium-rich foods when a child is taking furosemide helps ensure optimal medication effectiveness and reduces the risk of adverse effects. Understanding the rationale behind dietary recommendations empowers caregivers to actively participate in their child's care and promotes better outcomes in pediatric cardiovascular management.

Correct Answer: D

Rationale: In the first 24 to 48 hours after surgery, the body temperature may increase to 37.7° C (100° F) as part of the inflammatory response to tissue trauma. If the temperature is higher or continues after this period, it is most likely a sign of an infection and immediate investigation is indicated. Blankets should be removed from the child to keep the temperature from increasing. Hypothermia blanket is not indicated for this level of temperature. The temperature should be recorded, but the physician must be notified for evaluation. Suctioning should be done only as indicated, not on a routine basis. The child should be suctioned for no more than 5 seconds at one time. Symptoms of respiratory distress are avoided by using appropriate technique.