The nurse is caring for an infant diagnosed with hypoplastic left heart syndrome. The client has recently been scheduled for surgery to repair the defect. Which procedure does the nurse anticipate needing to provide client teaching about to the client's family?

Correct Answer: A

Rationale: The Norwood procedure is a surgical technique used to treat hypoplastic left heart syndrome, a congenital heart defect where the left side of the heart is underdeveloped. In this procedure, the surgeon creates a new functional aorta and reconstructs the right ventricle to take over pumping blood to both the lungs and the body. This procedure is typically performed in 3 stages, with the first stage usually done in the first week of life. Providing client teaching about the Norwood procedure is important for the family to understand the surgery, postoperative care, and potential complications. It helps prepare them for what to expect and how to best support their infant through the surgical and recovery process.

Correct Answer: B

Rationale: In the context of a client with disseminated intravascular coagulation (DIC) and a nursing diagnosis of Ineffective Peripheral Tissue Perfusion, elevating the client's knees on the bed or with a pillow is the most appropriate intervention. Elevating the knees promotes venous return and helps improve circulation to the peripheral tissues, thereby aiding in perfusion. Monitoring the client's level of consciousness and mental status (Option A) is important but not directly related to improving peripheral tissue perfusion in this case. Minimizing the use of tape on the client's skin (Option C) is a good practice to prevent skin damage but is not a priority for addressing ineffective peripheral tissue perfusion. Assessing extremity pulses, warmth, and capillary refill (Option D) is essential for evaluating perfusion status, but it is an assessment rather than an intervention to directly improve perfusion. In an educational context, understanding the rationale behind interventions for ineffective peripheral tissue perfusion in clients with DIC is crucial for nurses to provide effective care. Elevating the knees is a practical, evidence-based intervention that directly addresses the issue of poor perfusion in the extremities, highlighting the importance of targeted nursing interventions based on a thorough understanding of the client's condition.

Correct Answer: A

Rationale: In caring for a client with hypertension, the nurse may anticipate ordering diagnostic tests to identify any underlying secondary causes contributing to the elevated blood pressure. In this scenario, a cerebral angiogram would be the most appropriate test to rule out secondary causes such as intracranial abnormalities impacting blood pressure regulation. Option A, a cerebral angiogram, is correct because it assesses blood flow in the brain and can detect abnormalities like tumors or vascular malformations that could be causing the hypertension. Options B, C, and D are incorrect for ruling out secondary causes of hypertension. An intravenous pyelogram (option B) is used to visualize the urinary system, not typically associated with hypertension etiology. Renal ultrasonography (option C) focuses on the structure and size of the kidneys, valuable in assessing renal function but not the primary test for secondary causes of hypertension. Cardiac catheterization (option D) is more relevant for assessing coronary artery disease and cardiac function, less likely to reveal secondary causes of hypertension. Educationally, understanding the rationale behind diagnostic test selection is crucial for nurses to provide comprehensive care to clients with hypertension. It ensures appropriate interventions based on accurate diagnostic findings, enhancing patient outcomes and promoting a holistic approach to healthcare.

Correct Answer: D

Rationale: Early preeclampsia is a condition characterized by high blood pressure and signs of damage to another organ system, commonly the liver and kidneys. Severe epigastric pain is a common symptom of this organ involvement. It is caused by liver distention due to the breakdown of red blood cells and platelets, which can lead to a condition known as HELLP syndrome. This manifestation is a significant indicator of early preeclampsia and requires prompt evaluation and intervention to prevent complications for both the mother and the baby. While the other options may be present in preeclampsia, severe epigastric pain is a more specific and concerning symptom requiring immediate attention.

Correct Answer: B

Rationale: Keeping the extremities warm (Choice B) is the appropriate nursing intervention for a client with peripheral vascular disease (PVD) experiencing pain. Maintaining warmth helps promote vasodilation and improve blood flow to the affected areas, reducing pain and discomfort. Cold temperatures can exacerbate vasoconstriction and worsen symptoms in individuals with PVD. Elevating the legs in bed (Choice A) may be beneficial in some cases to improve circulation, but in the context of pain management for PVD, keeping the extremities warm is more pertinent. Encouraging ambulation (Choice C) can also help improve circulation, but it may not be suitable during episodes of pain. Applying cool compresses (Choice D) is contraindicated for PVD-related pain as it can further exacerbate vasoconstriction and discomfort.