ATI RN
Pediatric Nursing Cardiovascular Disorders Questions
Question 1 of 5
An infant with congestive heart failure is receiving digoxin (Lanoxin). What does the nurse recognize as a sign of digoxin toxicity?
Correct Answer: D
Rationale: In pediatric nursing, understanding the signs of digoxin toxicity is crucial due to the narrow therapeutic window of this medication. The correct answer is D) Vomiting. Digoxin toxicity commonly presents with gastrointestinal symptoms like vomiting, which can be an early sign of overdose in infants. Vomiting can lead to decreased oral intake, worsening dehydration, and electrolyte imbalances, further exacerbating toxicity. Option A) Restlessness is not a typical sign of digoxin toxicity in infants. It is more commonly associated with other conditions or medications. Option B) Decreased respiratory rate is not a typical manifestation of digoxin toxicity; rather, it may indicate respiratory distress or other respiratory conditions. Option C) Increased urinary output is not a typical sign of digoxin toxicity; instead, toxicity is more likely to cause decreased urinary output due to impaired renal function. Educationally, nurses must be vigilant in monitoring for signs of digoxin toxicity in pediatric patients to prevent serious complications. Understanding the specific signs and symptoms of toxicity, such as vomiting in this case, allows for early detection and intervention to ensure patient safety and optimal outcomes. Regular assessment and knowledge of medication-specific adverse effects are essential components of pediatric nursing practice.
Question 2 of 5
A client who weighs 175 pounds is receiving IV bolus dose of heparin 80 units/kg. The heparin is available in a 2 ml vial, labeled 10,000 units/ml. How many ml should the nurse administer? (Enter numeric value only. If rounding is required, round to the nearest tenth.)
Correct Answer: A
Rationale: In this pharmacology question, the correct answer is A) 0.6 ml. To calculate the correct dosage, the nurse first needs to determine the client's weight in kilograms (175 lbs ÷ 2.2 = 79.5 kg). Then, the nurse calculates the heparin dose by multiplying the weight in kg by the prescribed dose (80 units/kg x 79.5 kg = 6,360 units). Next, the nurse needs to determine how many ml of the 10,000 units/ml heparin vial to administer (6,360 units ÷ 10,000 units/ml = 0.636 ml). Rounding to the nearest tenth, the nurse should administer 0.6 ml. Option B) 0 is incorrect because the nurse should administer a dose of heparin based on the client's weight and the prescribed dosage. Option C) 6 is incorrect because it represents the total units of heparin required, not the volume in ml that should be administered. Option D) 1 is incorrect as it does not accurately reflect the calculated dose based on the client's weight and the concentration of the heparin vial. This question provides essential pharmacological calculations for pediatric nursing students. Understanding how to calculate medication dosages based on a client's weight and available concentrations is crucial for safe and effective pediatric patient care. This scenario also reinforces the importance of accurate dosage calculations to prevent medication errors and ensure optimal patient outcomes.
Question 3 of 5
The nurse is providing preoperative education for a Jewish client scheduled to receive a xenograft graft to promote burn healing. Which information should the nurse provide this client?
Correct Answer: B
Rationale: In this scenario, the correct answer is B) The xenograft is taken from nonhuman sources. Explanation: Xenografts are skin grafts taken from a different species, such as pig or cow, and used in burn patients to promote healing. Providing this information to a Jewish client is crucial for cultural sensitivity, as some Jewish individuals may have dietary restrictions or beliefs that impact their acceptance of treatments involving nonhuman sources. Why others are wrong: A) Grafting increases the risk for bacterial infections: While this is a potential risk associated with any type of grafting procedure, it is not specific to xenografts and is not the most pertinent information for preoperative education in this case. C) Grafts are later removed by a debriding procedure: This statement is inaccurate as xenografts are typically used as temporary coverings until the patient's own skin can be used for grafting, and they are not removed by debriding procedures. D) As the burn heals, the graft permanently attaches: This statement is incorrect as xenografts are temporary and eventually slough off as the patient's own skin regenerates underneath. Educational context: Understanding the source and nature of the graft is essential for the client's informed decision-making and compliance with the treatment plan. Providing culturally sensitive and accurate information ensures effective communication and fosters trust between the healthcare provider and the client.
Question 4 of 5
An overweight, young adult made who was recently diagnosed with type 2 diabetes mellitus is admitted for a hernia repair. He tells the nurse that he is feeling very weak and jittery. Which actions should the nurse implement? (Select all that apply.)
Correct Answer: C
Rationale: In this scenario, the correct action for the nurse to implement is to measure the patient's pulse and blood pressure (Option C). This is crucial because the patient is experiencing symptoms of weakness and jitteriness, which could indicate hypoglycemia, a common complication in diabetes management. Checking the pulse and blood pressure can help assess the patient's hemodynamic status and provide valuable information about his overall condition. Option A (Checking his fingerstick glucose level) could also be important in this situation to confirm if the patient's symptoms are indeed related to hypoglycemia. However, measuring the pulse and blood pressure takes precedence as it provides immediate data on the patient's cardiovascular status, especially during a perioperative period. Options B (Assessing his skin temperature and moisture) and D (Documenting anxiety on the surgical checklist) are not the most appropriate actions to take in response to the patient's symptoms. While assessing skin temperature and moisture can provide some information about the patient's perfusion status, it may not directly address the immediate concern of weakness and jitteriness. Documenting anxiety, although important for holistic care, does not address the physiological symptoms the patient is experiencing and should not be the priority in this situation. From an educational perspective, this scenario highlights the importance of prioritizing nursing actions based on the patient's presenting symptoms and clinical context. Understanding the significance of assessing vital signs in a timely manner, especially in patients with comorbid conditions like diabetes, is crucial for providing safe and effective care. It also underscores the need for nurses to be adept at recognizing and managing potential complications in patients with chronic illnesses undergoing surgical procedures.
Question 5 of 5
A client who has a history of hypothyroidism was initially admitted with lethargy and confusion. Which additional finding warrants the most immediate action by the nurse?
Correct Answer: D
Rationale: In this scenario, the most immediate action by the nurse should be prompted by the further decline in the level of consciousness (Option D). This is crucial because a worsening level of consciousness can indicate a deterioration in the client's condition, potentially leading to life-threatening complications. In pediatric patients, changes in mental status are critical indicators of systemic compromise and require immediate attention to prevent adverse outcomes. Option A, facial puffiness and periorbital edema, are common symptoms of hypothyroidism and may not require immediate action unless severe or accompanied by other concerning signs. Option B, a hematocrit of 30%, while low, may not be the most immediate concern compared to a declining level of consciousness. It could indicate anemia, which should be addressed but is not as urgent as a neurological deterioration. Option C, cold and dry skin, is also a symptom of hypothyroidism and may not warrant immediate action unless it is severe and contributing to the decline in the client's condition. In an educational context, understanding the prioritization of assessments and interventions based on the urgency of the client's condition is vital in pediatric nursing. This case highlights the importance of recognizing changes in consciousness as a red flag requiring immediate attention to prevent further deterioration and ensure optimal patient outcomes.