Test Bank For Wongs Essentials of Pediatric Nursing 11th
Edition Hockenberry; Wilson; Rodgers | 9780323624190|
Chapter 1-31| All Chapters with Answers and Rationals
An infant with an unrepaired tetralogy of Fallot defect is becoming extremely cyanotic
during a routine blood draw. Which interventions should the nurse implement? Place in order from
the highest-priority intervention to the lowest-priority intervention. Provide the answer using
lowercase letters separated by commas (e.g., a, b, c, d).
a. Administer 100% oxygen by blow-by.
b. Place the infant in knee-chest position.
c. Remain calm.
d. Give morphine subcutaneously or by an existing intravenous line. - ANSWER: b. Place the infant in
knee-chest position.
a. Administer 100% oxygen by blow-by.
d. Give morphine subcutaneously or by an existing intravenous line.
c. Remain calm.
ANS:
b, a, d, c
Hypercyanotic spells, also referred to as blue spells or tet spells because they are often seen in infants
with tetralogy of Fallot, may occur in any child whose heart defect includes obstruction to pulmonary
blood flow and communication between the ventricles. The infant becomes acutely cyanotic and
hyperpneic because sudden infundibular spasm decreases pulmonary blood flow and increases right-
to-
left shunting. Because profound hypoxemia causes cerebral hypoxia, hypercyanotic spells require
prompt
assessment and treatment to prevent brain damage or possibly death. The infant should first be
placed in
the knee-chest position to reduce blood returning to the heart. Next 100% oxygen is given to alleviate
the
hypoxemia. Morphine is next administered to reduce infundibular spasms. Last, the nurse should
remain
calm.
DIF: Cognitive Level: Apply REF: p. 741
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
1. A chest radiograph film is ordered for a child with suspected cardiac problems. Thechild's parent
asks the nurse, "What will the radiograph show about the heart?" What knowledge
about the x-ray should the nurse include in the response to the parents?
a. Bones of chest but not the heart
b. Measurement of electrical potential generated from heart muscle
c. Permanent record of heart size and configuration
,d. Computerized image of heart vessels and tissues - ANSWER: c. Permanent record of heart size and
configuration
ANS: C
A chest radiograph will provide information on the heart size and pulmonary blood-flow patterns. It
will
provide a baseline for future comparisons. The heart will be visible, as well as the sternum and ribs.
Electrocardiography (ECG) measures the electrical potential generated from heart muscle.
Echocardiography will produce a computerized image of the heart vessels and tissues by using sound
waves.
DIF: Cognitive Level: Understand REF: p. 738
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
2. The nurse is assessing a child after a cardiac catheterization. Which complication should
the nurse be assessing for?
a. Cardiac arrhythmia
b. Hypostatic pneumonia
c. Heart failure
d. Rapidly increasing blood pressure - ANSWER: a. Cardiac arrhythmia
ANS: A
Because a catheter is introduced into the heart, a risk exists of catheter-induced dysrhythmias
occurring
during the procedure. These are usually transient. Hypostatic pneumonia, heart failure, and rapidly
increasing blood pressure are not risks usually associated with cardiac catheterization.
DIF: Cognitive Level: Apply REF: p. 739
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
3. José is a 4-year-old child scheduled for a cardiac catheterization. What should be
included in preoperative teaching?
a. Directed at his parents because he is too young to understand
b. Detailed in regard to the actual procedures so he will know what to expect
c. Done several days before the procedure so that he will be prepared
d. Adapted to his level of development so that he can understand - ANSWER: ANS: D
d. Adapted to his level of development so that he can understand
Preoperative teaching should always be directed at the child's stage of development. The caregivers
also
benefit from the same explanations. The parents may ask additional questions, which should be
answered,
but the child needs to receive the information based on developmental level. Preschoolers will not
understand in-depth descriptions and should be prepared close to the time of the cardiac
catheterization.
, DIF: Cognitive Level: Apply REF: p. 739
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Health Promotion and Maintenance
4. Which explanation regarding cardiac catheterization is appropriate for a preschool
child?
a. Postural drainage will be performed every 4 to 6 hours after the test.
b. It is necessary to be completely "asleep" during the test.
c. The test is short, usually taking less than 1 hour.
d. When the procedure is done, you will have to keep your leg straight for at least
4 hours. - ANSWER: d. When the procedure is done, you will have to keep your leg straight for at least
4 hours.
ANS: D
The child's leg will have to be maintained in a straight position for approximately 4 hours. Younger
children can be held in the parent's lap with the leg maintained in the correct position. Postural
drainage
will not be performed unless the child has corresponding pulmonary problems. The child should be
sedated to lie still, but being completely asleep is not necessary. The test will vary in length of time
from
start to finish.
5. The nurse is caring for a school-age child who has had a cardiac catheterization. The
child tells the nurse that the bandage is "too wet." The nurse finds the bandage and bed soaked with
blood. What is the priority nursing action?
a. Notify physician
b. Apply new bandage with more pressure
c. Place the child in Trendelenburg position
d. Apply direct pressure above catheterization site - ANSWER: d. Apply direct pressure above
catheterization site
ANS: D
If bleeding occurs, direct continuous pressure is applied 2.5 cm (1 inch) above the percutaneous skin
site
to localize pressure over the vessel puncture. Notifying a physician and applying a new bandage can
be
done after pressure is applied. The nurse can have someone else notify the physician while the
pressure is
being maintained. It is not a helpful intervention to place the girl in the Trendelenburg position. It
would
increase the drainage from the lower extremities.
6. The nurse is preparing an adolescent for discharge after a cardiac catheterization. Which
statement by the adolescent would indicate a need for further teaching?
a. "I should avoid tub baths but may shower."
b. "I have to stay on strict bed rest for 3 days."
c. "I should remove the pressure dressing the day after the procedure."
d. "I may attend school but should avoid exercise for several days." - ANSWER: b. "I have to stay on
strict bed rest for 3 days."
Edition Hockenberry; Wilson; Rodgers | 9780323624190|
Chapter 1-31| All Chapters with Answers and Rationals
An infant with an unrepaired tetralogy of Fallot defect is becoming extremely cyanotic
during a routine blood draw. Which interventions should the nurse implement? Place in order from
the highest-priority intervention to the lowest-priority intervention. Provide the answer using
lowercase letters separated by commas (e.g., a, b, c, d).
a. Administer 100% oxygen by blow-by.
b. Place the infant in knee-chest position.
c. Remain calm.
d. Give morphine subcutaneously or by an existing intravenous line. - ANSWER: b. Place the infant in
knee-chest position.
a. Administer 100% oxygen by blow-by.
d. Give morphine subcutaneously or by an existing intravenous line.
c. Remain calm.
ANS:
b, a, d, c
Hypercyanotic spells, also referred to as blue spells or tet spells because they are often seen in infants
with tetralogy of Fallot, may occur in any child whose heart defect includes obstruction to pulmonary
blood flow and communication between the ventricles. The infant becomes acutely cyanotic and
hyperpneic because sudden infundibular spasm decreases pulmonary blood flow and increases right-
to-
left shunting. Because profound hypoxemia causes cerebral hypoxia, hypercyanotic spells require
prompt
assessment and treatment to prevent brain damage or possibly death. The infant should first be
placed in
the knee-chest position to reduce blood returning to the heart. Next 100% oxygen is given to alleviate
the
hypoxemia. Morphine is next administered to reduce infundibular spasms. Last, the nurse should
remain
calm.
DIF: Cognitive Level: Apply REF: p. 741
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
1. A chest radiograph film is ordered for a child with suspected cardiac problems. Thechild's parent
asks the nurse, "What will the radiograph show about the heart?" What knowledge
about the x-ray should the nurse include in the response to the parents?
a. Bones of chest but not the heart
b. Measurement of electrical potential generated from heart muscle
c. Permanent record of heart size and configuration
,d. Computerized image of heart vessels and tissues - ANSWER: c. Permanent record of heart size and
configuration
ANS: C
A chest radiograph will provide information on the heart size and pulmonary blood-flow patterns. It
will
provide a baseline for future comparisons. The heart will be visible, as well as the sternum and ribs.
Electrocardiography (ECG) measures the electrical potential generated from heart muscle.
Echocardiography will produce a computerized image of the heart vessels and tissues by using sound
waves.
DIF: Cognitive Level: Understand REF: p. 738
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
2. The nurse is assessing a child after a cardiac catheterization. Which complication should
the nurse be assessing for?
a. Cardiac arrhythmia
b. Hypostatic pneumonia
c. Heart failure
d. Rapidly increasing blood pressure - ANSWER: a. Cardiac arrhythmia
ANS: A
Because a catheter is introduced into the heart, a risk exists of catheter-induced dysrhythmias
occurring
during the procedure. These are usually transient. Hypostatic pneumonia, heart failure, and rapidly
increasing blood pressure are not risks usually associated with cardiac catheterization.
DIF: Cognitive Level: Apply REF: p. 739
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential
3. José is a 4-year-old child scheduled for a cardiac catheterization. What should be
included in preoperative teaching?
a. Directed at his parents because he is too young to understand
b. Detailed in regard to the actual procedures so he will know what to expect
c. Done several days before the procedure so that he will be prepared
d. Adapted to his level of development so that he can understand - ANSWER: ANS: D
d. Adapted to his level of development so that he can understand
Preoperative teaching should always be directed at the child's stage of development. The caregivers
also
benefit from the same explanations. The parents may ask additional questions, which should be
answered,
but the child needs to receive the information based on developmental level. Preschoolers will not
understand in-depth descriptions and should be prepared close to the time of the cardiac
catheterization.
, DIF: Cognitive Level: Apply REF: p. 739
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Health Promotion and Maintenance
4. Which explanation regarding cardiac catheterization is appropriate for a preschool
child?
a. Postural drainage will be performed every 4 to 6 hours after the test.
b. It is necessary to be completely "asleep" during the test.
c. The test is short, usually taking less than 1 hour.
d. When the procedure is done, you will have to keep your leg straight for at least
4 hours. - ANSWER: d. When the procedure is done, you will have to keep your leg straight for at least
4 hours.
ANS: D
The child's leg will have to be maintained in a straight position for approximately 4 hours. Younger
children can be held in the parent's lap with the leg maintained in the correct position. Postural
drainage
will not be performed unless the child has corresponding pulmonary problems. The child should be
sedated to lie still, but being completely asleep is not necessary. The test will vary in length of time
from
start to finish.
5. The nurse is caring for a school-age child who has had a cardiac catheterization. The
child tells the nurse that the bandage is "too wet." The nurse finds the bandage and bed soaked with
blood. What is the priority nursing action?
a. Notify physician
b. Apply new bandage with more pressure
c. Place the child in Trendelenburg position
d. Apply direct pressure above catheterization site - ANSWER: d. Apply direct pressure above
catheterization site
ANS: D
If bleeding occurs, direct continuous pressure is applied 2.5 cm (1 inch) above the percutaneous skin
site
to localize pressure over the vessel puncture. Notifying a physician and applying a new bandage can
be
done after pressure is applied. The nurse can have someone else notify the physician while the
pressure is
being maintained. It is not a helpful intervention to place the girl in the Trendelenburg position. It
would
increase the drainage from the lower extremities.
6. The nurse is preparing an adolescent for discharge after a cardiac catheterization. Which
statement by the adolescent would indicate a need for further teaching?
a. "I should avoid tub baths but may shower."
b. "I have to stay on strict bed rest for 3 days."
c. "I should remove the pressure dressing the day after the procedure."
d. "I may attend school but should avoid exercise for several days." - ANSWER: b. "I have to stay on
strict bed rest for 3 days."
