The nurse is caring for an infant diagnosed with "failure to thrive." The nurse observes the physician taking blood pressures in all four extremities and recognizes that the physician suspects which congenital cardiac defect?
1. Tetralogy of Fallot
2. Ventricular septal defect
3. Pulmonary atresia
4. Coarctation of the aorta
4
Rationale 1: There are minimal differences between upper and lower blood pressure readings in tetralogy of Fallot.
Rationale 2: There are minimal differences between upper and lower blood pressure readings in ventricular septal defect.
Rationale 3: There are minimal differences between upper and lower blood pressure readings in pulmonary atresia.
Rationale 4: Normally, blood pressures in the lower extremities are the same or higher than upper-extremity blood pressures. But in coarctation of the aorta, the narrowing of the aorta causes decreased blood flow to the lower extremities, and so lower extremity blood pressure readings are significantly lower than upper-extremity readings.
Global Rationale:
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A nurse wants to explore why clients who receive patient-controlled analgesia (PCA) after abdominal surgery ambulate sooner than clients who receive nurse-administered pain medications. Which action should the nurse take first?
a. Contact the medical center's clinical pharmacist. b. Search the medical library for the best evidence. c. Recommend PCA for all clients. d. Appraise data obtained through client chart audits.
An anxious patient enters the emergency room with angioedema of the lips and tongue, dyspnea, urticaria, and wheezing after having eaten a peanut butter sandwich. What should be the nurse's first intervention?
a. Apply cool compresses to urticaria b. Provide oxygen per non-rebreathing mask c. Cover patient with a warm blanket d. Prepare for venipuncture for the delivery of IV medication
A client with gout has not responded to the usual medications. The primary health care provider prescribes a pegloticase infusion. Based on the nurse's understanding of this drug, which nursing diagnosis would be most appropriate?
A) Risk for Injury B) Acute Pain C) Impaired Comfort: Gastric Distress D) Risk for Allergic Response
The client has asked you to do something but you do not know how to do it. You should
a. ask the other homemaker/home health aide who usually works for this client how to do it b. call the case manager and tell him or her the client has asked you to do something you cannot do c. look in the procedures manual and try to find out how to do it