The nurse is caring for a child who has just been diagnosed with an atrial septal defect (ASD). Which manifestations would the nurse expect upon assessment? Select all that apply.

Correct Answer: B

Rationale: Atrial septal defect (ASD) is a congenital heart defect where there is an abnormal opening between the atria of the heart. The manifestations of ASD can vary depending on the size of the defect and the individual. However, common manifestations may include:

Correct Answer: C

Rationale: The highest priority when caring for a patient with manifestations of appendicitis is to provide pain relief. By inserting a saline lock for intravenous pain medication, the patient can receive immediate pain relief to alleviate their discomfort. Pain management is crucial in appendicitis as it can help in improving the patient's overall well-being and reduce the risk of complications. While other options such as withholding food and fluids, performing preoperative skin preparation, or teaching postoperative exercises are important aspects of care, addressing the patient's pain is the top priority to ensure their comfort and well-being.

Correct Answer: C

Rationale: Swelling in one leg with edema is a classic sign of deep venous thrombosis (DVT). DVT occurs when a blood clot forms in one or more of the deep veins in the body, usually in the legs. This can lead to swelling in the affected leg due to the impaired venous return caused by the blood clot. It is important for the nurse to recognize this sign because if left untreated, DVT can lead to serious complications such as pulmonary embolism. Therefore, the nurse should further assess the client and notify the healthcare provider for appropriate management.

Correct Answer: D

Rationale: When performing medication teaching for the client's family about fibrinolytic therapy with alteplase (rt-PA), the nurse should include information that this medication is administered to break up existing clots and increase cerebral blood flow. rt-PA works by converting plasminogen to plasmin, which helps dissolve clots and restore blood flow to the brain. It is used specifically for ischemic strokes, not hemorrhagic strokes, and is most effective when administered within 3 hours (up to 4.5 hours in some cases) of the stroke symptoms starting. It is associated with potential serious complications, including an increased risk of bleeding, which the nurse should also educate the family about.

Correct Answer: B

Rationale: Assessing postural blood pressures is important in determining if the client may be experiencing orthostatic hypotension, which could have contributed to the fall. Orthostatic hypotension is a sudden drop in blood pressure that can occur when a person stands up from a sitting or lying position. Older adults on antihypertensive medications are at increased risk for orthostatic hypotension. By monitoring postural blood pressures, the nurse can identify fluctuations in blood pressure that may put the client at risk for falls and implement appropriate interventions to prevent future falls. Monitoring serum sodium levels and creatinine levels are important for detecting electrolyte imbalances or kidney dysfunction but do not directly address the issue of orthostatic hypotension related to falls. Monitoring blood pressure every 2 hours may not provide valuable information on postural blood pressure changes that are associated with orthostatic hypotension.

Correct Answer: C

Rationale: Disseminated intravascular coagulation (DIC) is a condition characterized by widespread activation of clotting factors throughout the body, leading to both excessive clot formation and consumption of clotting factors. As a result, one of the common features of DIC is a decreased level of fibrinogen, which is an essential protein for blood clot formation. In DIC, fibrinogen is consumed in the formation of multiple small blood clots throughout the circulation, causing a decrease in its levels. This decrease in fibrinogen can contribute to the increased risk of bleeding that is seen in DIC. Therefore, a decreased fibrinogen level is a characteristic laboratory finding in DIC.

Correct Answer: B

Rationale: Option B, washing the lower extremities with mild soap, drying the legs, and applying a light moisturizer, indicates effective teaching for a client with peripheral vascular disease (PVD). Proper hygiene, including gentle washing with mild soap, thorough drying to prevent moisture-related skin breakdown, and moisturizing to prevent dry skin and promote circulation, are key components of self-care for individuals with PVD. Option A is incorrect because sitting with a pillow behind the knees does not specifically address PVD self-care. Option C is incorrect because crossing the left leg over the right while sitting does not relate to appropriate PVD management. Option D is incorrect because smoking in any form is detrimental to vascular health and should be discouraged in PVD management.

Correct Answer: B

Rationale: When caring for a laboring client diagnosed with preeclampsia, it is important to be mindful of certain considerations to ensure the safety and well-being of both the mother and the baby. Placing the client in left lateral position when she feels the urge to push is crucial in cases of preeclampsia as it helps to optimize maternal and fetal oxygenation. This position can help improve blood flow to the placenta and reduce the risk of decreased perfusion due to the elevated blood pressure associated with preeclampsia. By maintaining the client in the left lateral position during pushing, it can help prevent potential complications and support better outcomes for both the mother and baby.

Correct Answer: C

Rationale: Evaluating client abilities to perform skills with return demonstrations is a good way for a nurse to prepare the environment for teaching. By observing the clients' abilities to perform the necessary skills, the nurse can tailor the teaching to meet the specific needs of each individual. Return demonstrations allow for immediate feedback and correction if needed, ensuring that the clients understand and can perform the skills accurately. This interactive approach to teaching promotes active learning and enhances retention of information.