Pediatric Cardiac Disorders NCLEX Questions Quizlet
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Question 1 of 5.
The client with atrial flutter is receiving a continuous infusion of 25,000 units of heparin in 500 mL of 5% dextrose at a rate of 12 mL per hour. The a PTT laboratory result is 92 seconds. According to the heparin infusion protocol, the nurse should administer the heparin infusion at a rate of how many mL per hour?
Answer: 11
Explanation: According to the protocol, with an aPTT value of 92 seconds, the rate should be decreased by 1 mL per hour. If the infusion was previously infusing at 12 mL per hour, the new rate is 11 mL/hr.
Question 2 of 5.
The nurse is developing a discharge-teaching plan for the client diagnosed with congestive heart failure. Which interventions should be included in the plan? Select all that apply.
A. Notify the health-care provider of a weight gain of more than one (1) pound in a week.
B. Teach the client how to count the radial pulse when taking digoxin, a cardiac glycoside.
C. Instruct the client to remove the saltshaker from the dinner table.
D. Encourage the client to monitor urine output for change in color to become dark.
E. Discuss the importance of taking the loop diuretic furosemide at bedtime.
Explanation: Weight gain monitoring (A) detects fluid retention, pulse counting (B) ensures digoxin safety, and removing salt (C) reduces sodium intake. Dark urine (D) is not specific, and furosemide at bedtime (E) causes nocturia, so morning dosing is preferred.
Question 3 of 5.
The nurse is assessing the client diagnosed with congestive heart failure. Which laboratory data would indicate that the client is in severe congestive heart failure?
A. An elevated B-type natriuretic peptide (BNP).
B. An elevated creatine kinase (CK-MB).
C. A positive D-dimer.
D. A positive ventilation/perfusion (V/Q) scan.
Explanation: Elevated BNP (A) is specific to heart failure, reflecting ventricular stress. CK-MB (B) indicates myocardial infarction, D-dimer (C) suggests clotting, and V/Q scan (D) is for pulmonary embolism.
Question 4 of 5.
The nurse and an unlicensed assistive personnel (UAP) are caring for four clients on a telemetry unit. Which nursing task would be best for the nurse to delegate to the UAP?
A. Assist the client to go down to the smoking area for a cigarette.
B. Transport the client to the intensive care unit (ICU) via a stretcher.
C. Provide the client going home discharge-teaching instructions.
D. Help position the client who is having a portable x-ray done.
Explanation: Positioning for an x-ray (D) is within the UAP's scope and safe. Smoking (A) is inappropriate, ICU transport (B) requires nursing judgment, and discharge teaching (C) is a nursing responsibility.
Question 5 of 5.
The nurse has written an outcome goal 'demonstrates tolerance for increased activity' for a client diagnosed with congestive heart failure. Which intervention should the nurse implement to assist the client to achieve this outcome?
A. Measure intake and output.
B. Provide two (2)g sodium diet.
C. Weigh the client daily.
D. Plan for frequent rest periods.
Explanation: Frequent rest periods (D) prevent overexertion, supporting activity tolerance in CHF. Intake/output (A), sodium diet (B), and daily weights (C) are important but less directly related to activity.
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