Exam (elaborations)
Chapter 46 The Child with a Cardiovascular Alteration
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- Nursing
- Institution
- University At Buffalo
Chapter 46 The Child with a Cardiovascular Alteration
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Chapter 46: The Child with a Cardiovascular AlterationTest Bank
MULTIPLE CHOICE
1. Which postoperative intervention should be questioned for a child after a
cardiac catheterization?
a. Continue intravenous (IV) fluids until the infant is tolerating oral fluids.
b. Check the dressing for bleeding.
c. Assess peripheral circulation on the affected extremity.
d. Keep the affected leg flexed and elevated.
ANS: D
Feedback
A IV fluid administration continues until the child is taking and retaining adequate
amounts of oral fluids.
B The insertion site dressing should be observed frequently for bleeding. The nurse
should also look under the child to check for pooled blood.
C Peripheral perfusion is monitored after catheterization. Distal pulses should be
palpable, although they may be weaker than in the contralateral extremity.
D The child should be positioned with the affected leg straight for 4 to 6 hours
after the procedure.
PTS: 1 DIF: Cognitive Level: Analysis REF: pp. 1212-1213
OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity
2. Which information should be included in the nurse’s discharge instructions for a child who
underwent a cardiac catheterization earlier in the day?
a. Pressure dressing is changed daily for the first week.
b. The child may soak in the tub beginning tomorrow.
c. Contact sports can be resumed in 2 days.
d. The child can return to school on the third day after the procedure.
ANS: D
Feedback
A The day after the cardiac catheterization, the pressure dressing is removed and
replaced with a Band-Aid. The catheter insertion site is assessed daily for
healing. Any bleeding or sign of infection, such as drainage, must be reported to
the cardiologist.
B Bathing is limited to a shower, a sponge bath, or a brief tub bath (no soaking) for
the first 1 to 3 days after the procedure.
C Strenuous exercise such as contact sports, swimming, or climbing trees is
avoided for up to 1 week after the procedure.
D The child can return to school on the third day after the procedure. It is important
to emphasize follow-up with the cardiologist.
PTS: 1 DIF: Cognitive Level: Application REF: p. 1213
, OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity
3. The nurse is admitting a child to the hospital for a cardiac workup. What is the first step in a
cardiac assessment?
a. Percussion
b. Palpation
c. Auscultation
d. History and inspection
ANS: D
Feedback
A Percussion of the chest is usually deferred.
B Palpation can be threatening to the child because it requires a significant amount
of physical contact. For this reason it is not the initial step in a cardiac
assessment.
C Auscultation requires touching the child and is not the initial step in a cardiac
assessment.
D The assessment should begin with the least threatening interventions—the
history and inspection. Assessment progression includes inspection, auscultation,
and palpation because each step includes more touching.
PTS: 1 DIF: Cognitive Level: Application REF: p. 1210 | Table 46-2
OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance
4. In which situation is there a risk that a newborn infant will have a congenital heart defect
(CHD)?
a. Trisomy 21 detected on amniocentesis
b. Family history of myocardial infarction
c. Father has type 1 diabetes mellitus
d. Older sibling born with Turner syndrome
ANS: A
Feedback
A The incidence of congenital heart disease is approximately 50% in children with
trisomy 21 (Down syndrome).
B A family history of congenital heart disease, not acquired heart disease,
increases the risk of giving birth to a child with CHD.
C Infants born to mothers who are insulin dependent have an increased risk of
CHD.
D Infants identified as having certain genetic defects, such as Turner syndrome,
have a higher incidence of CHD. A family history is not a risk factor.
PTS: 1 DIF: Cognitive Level: Application REF: p. 1201
OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance
5. Before giving a dose of digoxin (Lanoxin), the nurse checked an infant’s apical heart rate and
it was 114 bpm. What should the nurse do next?
a. Administer the dose as ordered.
b. Hold the medication until the next dose.
, c. Wait and recheck the apical heart rate in 30 minutes.
d. Notify the physician about the infant’s heart rate.
ANS: A
Feedback
A The infant’s heart rate is above the lower limit for which the medication is held.
The dose can be given.
B A dose of Lanoxin is withheld for a heart rate less than 100 bpm in an infant.
C The infant’s heart rate is acceptable for administering Lanoxin. It is unnecessary
to recheck the heart rate at a later time.
D The infant’s heart rate is acceptable. The physician should be notified for a heart
rate less than 100 bpm in an infant.
PTS: 1 DIF: Cognitive Level: Application REF: p. 1204
OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity
6. What intervention should be included in the plan of care for an infant with the nursing
diagnosis of Excess Fluid Volume related to congestive heart failure?
a. Weigh the infant every day on the same scale at the same time.
b. Notify the physician when weight gain exceeds more than 20 g/day.
c. Put the infant in a car seat to minimize movement.
d. Administer digoxin (Lanoxin) as ordered by the physician.
ANS: A
Feedback
A Excess fluid volume may not be overtly visible. Weight changes may indicate
fluid retention. Weighing the infant on the same scale at the same time each day
ensures consistency.
B An excessive weight gain for an infant is an increase of more than 50 g/day.
C With fluid volume excess, skin will be edematous. The infant’s position should
be changed frequently to prevent undesirable pooling of fluid in certain areas.
D Lanoxin is used in the treatment of congestive heart failure to improve cardiac
function. Diuretics will help the body get rid of excess fluid.
PTS: 1 DIF: Cognitive Level: Application REF: p. 1204
OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity
7. The nurse assessing a premature newborn infant auscultates a continuous machinery-like
murmur. This finding is associated with which congenital heart defect?
a. Pulmonary stenosis
b. Patent ductus arteriosus
c. Ventricular septal defect
d. Coarctation of the aorta
ANS: B
Feedback
A A systolic ejection murmur that may be accompanied by a palpable thrill is a
manifestation of pulmonary stenosis.
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