The nurse is caring for a 2-month-old child with transposition of the great vessels. Which of these interventions has highest priority?

Correct Answer: B

Rationale: The correct answer is B: Maintaining proper caloric intake. In a child with transposition of the great vessels, ensuring adequate nutrition is critical for growth and development. Without proper caloric intake, the child's health and recovery may be compromised. Providing comfort for parents (A) is important but not the highest priority. Reducing stressors for the infant (C) is valuable but not as crucial as ensuring proper nutrition. Documenting vital signs (D) is essential but does not directly address the immediate physiological needs of the child. Maintaining proper caloric intake should be the priority to support the child's overall well-being and aid in their recovery.

Correct Answer: C

Rationale: The correct answer is C because in a VVIR mode pacemaker: 1. Ventricular pacing: The pacemaker paces the ventricle. 2. Atrial sensing: It senses the atrial activity for timing. 3. Triggered response to sensing: It responds by pacing the ventricle after sensing an event. 4. Rate modulated: It can adjust the pacing rate based on the patient's physiological needs. Therefore, choice C accurately describes the characteristics of a VVIR mode pacemaker. Incorrect choices: A: Incorrect because it mentions atrial pacing, which is not a feature of VVIR mode. B: Incorrect because it includes ventricular sensing, which is not a feature of VVIR mode. D: Incorrect because it mentions ventricular sensing and inhibited response to sensing, which are not characteristics of VVIR mode pacemaker.

Correct Answer: C

Rationale: Step-by-step rationale: 1. Heparin is known to increase the risk of bleeding when used concomitantly with streptokinase. 2. Both drugs have anticoagulant properties, leading to a synergistic effect on bleeding risk. 3. Streptokinase enhances the activity of heparin, potentially causing excessive bleeding in the client. 4. This interaction highlights the importance of monitoring clotting parameters when these drugs are used together. Summary of incorrect choices: A: Cimetidine - Not known to interact significantly with streptokinase in terms of bleeding risk. B: Theophylline - Does not have a direct pharmacological interaction with streptokinase. D: Digoxin - Does not impact the bleeding risk associated with streptokinase.

Correct Answer: B

Rationale: The correct answer is B: An alpha agonist. Alpha agonists can cause vasoconstriction, leading to decreased blood flow and tissue necrosis at the IV site. Digoxin (A) is a cardiac glycoside used for heart conditions, not associated with tissue necrosis. Beta blockers (C) reduce heart rate and blood pressure, not causing tissue necrosis. Calcium channel blockers (D) relax blood vessels and are not typically linked to tissue necrosis.

Correct Answer: A

Rationale: Correct Answer: A (Nausea and vomiting) Rationale: Anti-arrhythmic drugs can affect the gastrointestinal system, leading to nausea and vomiting as common side effects. This is due to the drug's impact on the digestive tract and its receptors. Hypotension (choice B) is not a common side effect of anti-arrhythmic drugs as they are more likely to cause cardiac effects. Pro-arrhythmic effect (choice C) is a potential risk of anti-arrhythmic drugs but not a common side effect. Constipation (choice D) is not typically associated with anti-arrhythmic drugs, as they are more likely to affect the heart and not the digestive system.