An infant with a congenital cyanotic heart defect has a complete blood count drawn, revealing an elevated red blood cell (RBC) count. Which condition do these findings indicate?

Correct Answer: D

Rationale: The correct answer is D: Hypoxia compensation. In a cyanotic heart defect, there is decreased oxygenation, leading to hypoxia. The body compensates by increasing RBC production to improve oxygen-carrying capacity. Anemia (choice A) is a decrease in RBC count, not an increase. Dehydration (choice B) would typically lead to hemoconcentration but not specifically an elevated RBC count. Jaundice (choice C) is due to elevated bilirubin levels, unrelated to RBC count. Therefore, the elevated RBC count in this infant indicates a compensatory response to hypoxia, supporting choice D.

Correct Answer: B

Rationale: The correct answer is B because during the acute phase of rheumatic fever, the priority action of the nurse is to assess for early signs of endocarditis due to the risk of developing heart valve damage. Endocarditis is a serious complication of rheumatic fever that can lead to further cardiac issues. Monitoring for signs such as new or changing heart murmurs, fever, and signs of embolization is crucial for early detection and intervention. Choice A is incorrect because although ambulation is important for overall health, it is not the priority during the acute phase of rheumatic fever. Choice C is also incorrect as maintaining hydration is essential, but it is not the priority over monitoring for endocarditis. Choice D is incorrect as managing pain with strong narcotic analgesics is not the priority action during the acute phase of rheumatic fever.

Correct Answer: C

Rationale: The correct answer is C: Elevated pulmonary artery wedge pressure (PAWP) or PAOP. In this scenario, the blockage in the left coronary artery is causing a decrease in cardiac output, leading to heart failure and pulmonary edema. Elevated PAWP indicates increased pressure in the left side of the heart, reflecting the back pressure that causes fluid to leak into the lungs. A: Elevated central venous pressure is more indicative of right heart failure, not directly related to left coronary artery blockage. B: Elevated blood pressure is not typically associated with pulmonary edema from left coronary artery blockage. D: Increased oxygen saturation would not be a typical finding in pulmonary edema due to decreased gas exchange in the lungs.

Correct Answer: A

Rationale: The correct answer is A because it demonstrates the patient's understanding of the importance of avoiding electromagnetic interference, which can disrupt the functioning of the pacemaker. Handling the pacemaker leads at the same time as the toaster can generate electromagnetic interference. Option B is incorrect because obtaining a medic alert tag is important for emergency identification but does not directly relate to pacemaker care. Option C is incorrect as the patient should always be vigilant about infection risks regardless of where the pacemaker was implanted. Option D is incorrect as modern pacemakers are designed to withstand low levels of microwave radiation and being around a home microwave is generally safe.

Correct Answer: B

Rationale: In this scenario, the correct answer is option B) Pain or dyspnea occur. This is the most appropriate response because pain or dyspnea during exercise can indicate a significant issue with the cardiovascular system. It could be a sign of angina, myocardial infarction, or another serious cardiac event that requires immediate attention. Stopping exercise when experiencing these symptoms is crucial for the patient's safety. Option A) The HR exceeds 150 beats per minute is not the best choice because heart rate can vary greatly depending on the individual's fitness level. While exceeding 150 bpm may be a concern for some, it is not a definitive indicator to stop exercise for all patients. Option C) The respiratory rate increases to 30 breaths per minute is also not as critical as option B. An increased respiratory rate could be due to factors other than cardiac issues, such as poor fitness level or environmental conditions. Option D) The HR is 15 beats over the resting heart rate is a vague and arbitrary measure. It does not account for individual variability in heart rate response to exercise and may not accurately reflect the patient's physiological limits. In an educational context, it is important to teach patients in cardiac rehabilitation programs about the signs and symptoms that warrant stopping exercise. Understanding these warning signs can help prevent serious complications and promote safe participation in physical activity. Encouraging patients to listen to their bodies and seek medical attention if they experience pain or difficulty breathing during exercise is essential for their well-being.