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Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

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250 questions, answers, and explanations are offered in this sample exam from the 2013 edition of NCLEX-RN Exam Cram.

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  • A 43-year-old African American male is admitted with sickle cell anemia. The nurse plans to assess circulation in the lower extremities every two hours. Which of the following outcome criteria would the nurse use?

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    Body temperature of 99°F or less

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    Toes moved in active range of motion

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    Sensation reported when soles of feet are touched

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    Capillary refill of < 3 seconds

    Quick Answer: 223

    Detailed Answer: 225

  • A 30-year-old male from Haiti is brought to the emergency department in sickle cell crisis. What is the best position for this client?

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    Side-lying with knees flexed

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    Knee-chest

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    High Fowler’s with knees flexed

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    Semi-Fowler’s with legs extended on the bed

    Quick Answer: 223

    Detailed Answer: 225

  • A 25-year-old male is admitted in sickle cell crisis. Which of the following interventions would be of highest priority for this client?

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    Taking hourly blood pressures with mechanical cuff

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    Encouraging fluid intake of at least 200mL per hour

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    Position in high Fowler’s with knee gatch raised

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    Administering Tylenol as ordered

    Quick Answer: 223

    Detailed Answer: 225

  • Which of the following foods would the nurse encourage the client in sickle cell crisis to eat?

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    Steak

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    Cottage cheese

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    Popsicle

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    Lima beans

    Quick Answer: 223

    Detailed Answer: 225

  • A newly admitted client has sickle cell crisis. He is complaining of pain in his feet and hands. The nurse’s assessment findings include a pulse oximetry of 92. Assuming that all the following interventions are ordered, which should be done first?

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    Adjust the room temperature

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    Give a bolus of IV fluids

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    Start O2

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    Administer meperidine (Demerol) 75mg IV push

    Quick Answer: 223

    Detailed Answer: 225

  • The nurse is instructing a client with iron-deficiency anemia. Which of the following meal plans would the nurse expect the client to select?

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    Roast beef, gelatin salad, green beans, and peach pie

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    Chicken salad sandwich, coleslaw, French fries, ice cream

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    Egg salad on wheat bread, carrot sticks, lettuce salad, raisin pie

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    Pork chop, creamed potatoes, corn, and coconut cake

    Quick Answer: 223

    Detailed Answer: 225

  • Clients with sickle cell anemia are taught to avoid activities that cause hypoxia and hypoxemia. Which of the following activities would the nurse recommend?

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    A family vacation in the Rocky Mountains

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    Chaperoning the local boys club on a snow-skiing trip

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    Traveling by airplane for business trips

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    A bus trip to the Museum of Natural History

    Quick Answer: 223

    Detailed Answer: 225

  • The nurse is conducting an admission assessment of a client with vitamin B12 deficiency. Which finding reinforces the diagnosis of B12 deficiency?

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    Enlarged spleen

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    Elevated blood pressure

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    Bradycardia

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    Beefy tongue

    Quick Answer: 223

    Detailed Answer: 225

  • The body part that would most likely display jaundice in the dark-skinned individual is the:

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    Conjunctiva of the eye

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    Soles of the feet

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    Roof of the mouth

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    Shins

    Quick Answer: 223

    Detailed Answer: 225

  • The nurse is conducting a physical assessment on a client with anemia. Which of the following clinical manifestations would be most indicative of the anemia?

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    BP 146/88

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    Respirations 28 shallow

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    Weight gain of 10 pounds in six months

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    Pink complexion

    Quick Answer: 223

    Detailed Answer: 226

  • The nurse is teaching the client with polycythemia vera about prevention of complications of the disease. Which of the following statements by the client indicates a need for further teaching?

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    “I will drink 500mL of fluid or less each day.”

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    “I will wear support hose.”

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    “I will check my blood pressure regularly.”

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    “I will report ankle edema.”

    Quick Answer: 223

    Detailed Answer: 226

  • A 33-year-old male is being evaluated for possible acute leukemia. Which of the following findings is most likely related to the diagnosis of leukemia?

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    The client collects stamps as a hobby.

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    The client recently lost his job as a postal worker.

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    The client had radiation for treatment of Hodgkin’s disease as a teenager.

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    The client’s brother had leukemia as a child.

    Quick Answer: 223

    Detailed Answer: 226

  • Where is the best site for examining for the presence of petechiae in an African American client?

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    The abdomen

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    The thorax

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    The earlobes

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    The soles of the feet

    Quick Answer: 223

    Detailed Answer: 226

  • The client is being evaluated for possible acute leukemia. Which inquiry by the nurse is most important?

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    “Have you noticed a change in sleeping habits recently?”

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    “Have you had a respiratory infection in the last six months?”

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    “Have you lost weight recently?”

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    “Have you noticed changes in your alertness?”

    Quick Answer: 223

    Detailed Answer: 226

  • Which of the following would be the priority nursing diagnosis for the adult client with acute leukemia?

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    Oral mucous membrane, altered related to chemo-therapy

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    Risk for injury related to thrombocytopenia

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    Fatigue related to the disease process

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    Interrupted family processes related to life-threatening illness of a family member

    Quick Answer: 223

    Detailed Answer: 226

  • A 21-year-old male with Hodgkin’s lymphoma is a senior at the local university. He is engaged to be married and is to begin a new job upon graduation. Which of the following diagnoses would be a priority for this client?

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    Sexual dysfunction related to radiation therapy

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    Anticipatory grieving related to terminal illness

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    Tissue integrity related to prolonged bed rest

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    Fatigue related to chemotherapy

    Quick Answer: 223

    Detailed Answer: 226

  • A client has autoimmune thrombocytopenic purpura. To determine the client’s response to treatment, the nurse would monitor:

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    Platelet count

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    White blood cell count

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    Potassium levels

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    Partial prothrombin time (PTT)

    Quick Answer: 223

    Detailed Answer: 226

  • The home health nurse is visiting a client with autoimmune thrombocytopenic purpura (ATP). The client’s platelet count currently is 80,000. It will be most important to teach the client and family about:

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    Bleeding precautions

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    Prevention of falls

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    Oxygen therapy

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    Conservation of energy

    Quick Answer: 223

    Detailed Answer: 226

  • The client has surgery for removal of a Prolactinoma. Which of the following interventions would be appropriate for this client?

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    Place the client in Trendelenburg position for postural drainage.

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    Encourage coughing and deep breathing every two hours.

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    Elevate the head of the bed 30°.

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    Encourage the Valsalva maneuver for bowel movements.

    Quick Answer: 223

    Detailed Answer: 226

  • The client with a history of diabetes insipidus is admitted with polyuria, polydipsia, and mental confusion. The priority intervention for this client is:

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    Measure the urinary output.

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    Check the vital signs.

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    Encourage increased fluid intake.

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    Weigh the client.

    Quick Answer: 223

    Detailed Answer: 227

  • A client with hemophilia has a nosebleed. Which nursing action is most appropriate to control the bleeding?

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    Place the client in a sitting position.

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    Administer acetaminophen (Tylenol).

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    Pinch the soft lower part of the nose.

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    Apply ice packs to the forehead.

    Quick Answer: 223

    Detailed Answer: 227

  • A client has had a unilateral adrenalectomy to remove a tumor. The most important measurement in the immediate post-operative period for the nurse to take is:

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    The blood pressure

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    The temperature

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    The urinary output

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    The specific gravity of the urine

    Quick Answer: 223

    Detailed Answer: 227

  • A client with Addison’s disease has been admitted with a history of nausea and vomiting for the past three days. The client is receiving IV glucocorticoids (Solu-Medrol). Which of the following interventions would the nurse implement?

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    Glucometer readings as ordered

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    Intake/output measurements

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    Evaluating the sodium and potassium levels

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    Daily weights

    Quick Answer: 223

    Detailed Answer: 227

  • A client had a total thyroidectomy yesterday. The client is complaining of tingling around the mouth and in the fingers and toes. What would the nurses’ next action be?

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    Obtain a crash cart.

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    Check the calcium level.

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    Assess the dressing for drainage.

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    Assess the blood pressure for hypertension.

    Quick Answer: 223

    Detailed Answer: 227

  • A 32-year-old mother of three is brought to the clinic. Her pulse is 52, there is a weight gain of 30 pounds in four months, and the client is wearing two sweaters. The client is diagnosed with hypothyroidism. Which of the following nursing diagnoses is of highest priority?

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    Impaired physical mobility related to decreased endurance

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    Hypothermia r/t decreased metabolic rate

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    Disturbed thought processes r/t interstitial edema

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    Decreased cardiac output r/t bradycardia

    Quick Answer: 223

    Detailed Answer: 227

  • The client presents to the clinic with a serum cholesterol of 275mg/dL and is placed on rosuvastatin (Crestor). Which instruction should be given to the client taking rosuvastatin (Crestor)?

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    Report muscle weakness to the physician.

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    Allow six months for the drug to take effect.

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    Take the medication with fruit juice.

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    Report difficulty sleeping.

    Quick Answer: 223

    Detailed Answer: 227

  • The client is admitted to the hospital with hypertensive crises. Diazoxide (Hyperstat) is ordered. During administration, the nurse should:

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    Utilize an infusion pump.

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    Check the blood glucose level.

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    Place the client in Trendelenburg position.

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    Cover the solution with foil.

    Quick Answer: 223

    Detailed Answer: 227

  • The six-month-old client with a ventral septal defect is receiving Digitalis for regulation of his heart rate. Which finding should be reported to the doctor?

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    Blood pressure of 126/80

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    Blood glucose of 110mg/dL

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    Heart rate of 60bpm

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    Respiratory rate of 30 per minute

    Quick Answer: 223

    Detailed Answer: 227

  • The client admitted with angina is given a prescription for nitroglycerine. The client should be instructed to:

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    Replenish his supply every three months.

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    Take one every 15 minutes if pain occurs.

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    Leave the medication in the brown bottle.

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    Crush the medication and take with water.

    Quick Answer: 223

    Detailed Answer: 228

  • The client is instructed regarding foods that are low in fat and cholesterol. Which diet selection is lowest in saturated fats?

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    Macaroni and cheese

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    Shrimp with rice

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    Turkey breast

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    Spaghetti with meat sauce

    Quick Answer: 223

    Detailed Answer: 228

  • The client is admitted with left-sided congestive heart failure. In assessing the client for edema, the nurse should check the:

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    Feet

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    Neck

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    Hands

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    Sacrum

    Quick Answer: 223

    Detailed Answer: 228

  • The nurse is checking the client’s central venous pressure. The nurse should place the zero of the manometer at the:

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    Phlebostatic axis

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    PMI

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    Erb’s point

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    Tail of Spence

    Quick Answer: 223

    Detailed Answer: 228

  • The physician orders lisinopril (Zestril) and furosemide (Lasix) to be administered concomitantly to the client with hypertension. The nurse should:

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    Question the order.

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    Administer the medications.

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    Administer separately.

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    Contact the pharmacy.

    Quick Answer: 223

    Detailed Answer: 228

  • The best method of evaluating the amount of peripheral edema is:

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    Weighing the client daily

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    Measuring the extremity

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    Measuring the intake and output

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    Checking for pitting

    Quick Answer: 223

    Detailed Answer: 228

  • A client with vaginal cancer is being treated with a radioactive vaginal implant. The client’s husband asks the nurse if he can spend the night with his wife. The nurse should explain that:

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    Overnight stays by family members is against hospital policy.

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    There is no need for him to stay because staffing is adequate.

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    His wife will rest much better knowing that he is at home.

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    Visitation is limited to 30 minutes when the implant is in place.

    Quick Answer: 223

    Detailed Answer: 228

  • The nurse is caring for a client hospitalized with a facial stroke. Which diet selection would be suited to the client?

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    Roast beef sandwich, potato chips, pickle spear, iced tea

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    Split pea soup, mashed potatoes, pudding, milk

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    Tomato soup, cheese toast, Jello, coffee

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    Hamburger, baked beans, fruit cup, iced tea

    Quick Answer: 223

    Detailed Answer: 228

  • The physician has prescribed Novalog insulin for a client with diabetes mellitus. Which statement indicates that the client knows when the peak action of the insulin occurs?

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    “I will make sure I eat breakfast within 10 minutes of taking my insulin.”

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    “I will need to carry candy or some form of sugar with me all the time.”

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    “I will eat a snack around three o’clock each afternoon.”

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    “I can save my dessert from supper for a bedtime snack.”

    Quick Answer: 223

    Detailed Answer: 229

  • The nurse is teaching basic infant care to a group of first-time parents. The nurse should explain that a sponge bath is recommended for the first two weeks of life because:

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    New parents need time to learn how to hold the baby.

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    The umbilical cord needs time to separate.

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    Newborn skin is easily traumatized by washing.

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    The chance of chilling the baby outweighs the benefits of bathing.

    Quick Answer: 223

    Detailed Answer: 229

  • A client with leukemia is receiving Trimetrexate. After reviewing the client’s chart, the physician orders Wellcovorin (leucovorin calcium). The rationale for administering leucovorin calcium to a client receiving Trimetrexate is to:

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    Treat iron-deficiency anemia caused by chemotherapeutic agents

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    Create a synergistic effect that shortens treatment time

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    Increase the number of circulating neutrophils

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    Reverse drug toxicity and prevent tissue damage

    Quick Answer: 223

    Detailed Answer: 229

  • A four-month-old is brought to the well-baby clinic for immunization. In addition to the DPT and polio vaccines, the baby should receive:

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    Hib titer

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    Mumps vaccine

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    Hepatitis B vaccine

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    MMR

    Quick Answer: 223

    Detailed Answer: 229

  • The physician has prescribed Nexium (esomeprazole) for a client with erosive gastritis. The nurse should administer the medication:

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    30 minutes before a meal

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    With each meal

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    In a single dose at bedtime

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    30 minutes after meals

    Quick Answer: 223

    Detailed Answer: 229

  • A client on the psychiatric unit is in an uncontrolled rage and is threatening other clients and staff. What is the most appropriate action for the nurse to take?

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    Call security for assistance and prepare to sedate the client.

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    Tell the client to calm down and ask him if he would like to play cards.

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    Tell the client that if he continues his behavior he will be punished.

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    Leave the client alone until he calms down.

    Quick Answer: 223

    Detailed Answer: 229

  • When the nurse checks the fundus of a client on the first postpartum day, she notes that the fundus is firm, is at the level of the umbilicus, and is displaced to the right. The next action the nurse should take is to:

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    Check the client for bladder distention.

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    Assess the blood pressure for hypotension.

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    Determine whether an oxytocic drug was given.

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    Check for the expulsion of small clots.

    Quick Answer: 223

    Detailed Answer: 229

  • A client is admitted to the hospital with a temperature of 99.8°F, complaints of blood-tinged hemoptysis, fatigue, and night sweats. The client’s symptoms are consistent with a diagnosis of:

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    Pneumonia

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    Reaction to antiviral medication

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    Tuberculosis

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    Superinfection due to low CD4 count

    Quick Answer: 223

    Detailed Answer: 229

  • The client is seen in the clinic for treatment of migraine headaches. The drug Imitrex (sumatriptan succinate) is prescribed for the client. Which of the following in the client’s history should be reported to the doctor?

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    Diabetes

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    Prinzmetal’s angina

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    Cancer

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    Cluster headaches

    Quick Answer: 223

    Detailed Answer: 229

  • The client with suspected meningitis is admitted to the unit. The doctor is performing an assessment to determine meningeal irritation and spinal nerve root inflammation. A positive Kernig’s sign is charted if the nurse notes:

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    Pain on flexion of the hip and knee

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    Nuchal rigidity on flexion of the neck

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    Pain when the head is turned to the left side

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    Dizziness when changing positions

    Quick Answer: 223

    Detailed Answer: 229

  • The client with Alzheimer’s disease is being assisted with activities of daily living when the nurse notes that the client uses her toothbrush to brush her hair. The nurse is aware that the client is exhibiting:

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    Agnosia

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    Apraxia

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    Anomia

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    Aphasia

    Quick Answer: 223

    Detailed Answer: 229

  • The client with dementia is experiencing confusion late in the afternoon and before bedtime. The nurse is aware that the client is experiencing what is known as:

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    Chronic fatigue syndrome

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    Normal aging

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    Sundowning

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    Delusions

    Quick Answer: 223

    Detailed Answer: 230

  • The client with confusion says to the nurse, “I haven’t had anything to eat all day long. When are they going to bring breakfast?” The nurse saw the client in the day room eating breakfast with other clients 30 minutes before this conversation. Which response would be best for the nurse to make?

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    “You know you had breakfast 30 minutes ago.”

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    “I am so sorry that they didn’t get you breakfast. I’ll report it to the charge nurse.”

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    “I’ll get you some juice and toast. Would you like something else?”

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    “You will have to wait a while; lunch will be here in a little while.”

    Quick Answer: 223

    Detailed Answer: 230

  • The doctor has prescribed Exelon (rivastigmine) for the client with Alzheimer’s disease. Which side effect is most often associated with this drug?

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    Urinary incontinence

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    Headaches

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    Confusion

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    Nausea

    Quick Answer: 223

    Detailed Answer: 230

  • A client is admitted to the labor and delivery unit in active labor. During examination, the nurse notes a papular lesion on the perineum. Which initial action is most appropriate?

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    Document the finding.

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    Report the finding to the doctor.

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    Prepare the client for a C-section.

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    Continue primary care as prescribed.

    Quick Answer: 223

    Detailed Answer: 230

  • A client with a diagnosis of HPV is at risk for which of the following?

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    Hodgkin’s lymphoma

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    Cervical cancer

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    Multiple myeloma

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    Ovarian cancer

    Quick Answer: 223

    Detailed Answer: 230

  • During the initial interview, the client reports that she has a lesion on the perineum. Further investigation reveals a small blister on the vulva that is painful to touch. The nurse is aware that the most likely source of the lesion is:

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    Syphilis

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    Herpes

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    Gonorrhea

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    Condylomata

    Quick Answer: 223

    Detailed Answer: 230

  • A client visiting a family planning clinic is suspected of having an STI. The best diagnostic test for treponema pallidum is:

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    Venereal Disease Research Lab (VDRL)

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    Rapid plasma reagin (RPR)

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    Fluorescent treponemal antibody (FTA)

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    Thayer-Martin culture (TMC)

    Quick Answer: 223

    Detailed Answer: 230

  • A 15-year-old primigravida is admitted with a tentative diagnosis of HELLP syndrome. Which laboratory finding is associated with HELLP syndrome?

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    Elevated blood glucose

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    Elevated platelet count

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    Elevated creatinine clearance

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    Elevated hepatic enzymes

    Quick Answer: 223

    Detailed Answer: 230

  • The nurse is assessing the deep tendon reflexes of a client with preeclampsia. Which method is used to elicit the biceps reflex?

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    The nurse places her thumb on the muscle inset in the antecubital space and taps the thumb briskly with the reflex hammer.

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    The nurse loosely suspends the client’s arm in an open hand while tapping the back of the client’s elbow.

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    The nurse instructs the client to dangle her legs as the nurse strikes the area below the patella with the blunt side of the reflex hammer.

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    The nurse instructs the client to place her arms loosely at her side as the nurse strikes the muscle insert just above the wrist.

    Quick Answer: 223

    Detailed Answer: 230

  • A primigravida with diabetes is admitted to the labor and delivery unit at 34 weeks gestation. Which doctor’s order should the nurse question?

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    Magnesium sulfate 4gm (25%) IV

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    Brethine 10mcg IV

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    Stadol 1mg IV push every 4 hours as needed prn for pain

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    Ancef 2gm IVPB every 6 hours

    Quick Answer: 223

    Detailed Answer: 230

  • A diabetic multigravida is scheduled for an amniocentesis at 32 weeks gestation to determine the L/S ratio and phosphatidyl glycerol level. The L/S ratio is 1:1 and the presence of phosphatidylglycerol is noted. The nurse’s assessment of this data is:

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    The infant is at low risk for congenital anomalies.

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    The infant is at high risk for intrauterine growth retardation.

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    The infant is at high risk for respiratory distress syndrome.

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    The infant is at high risk for birth trauma.

    Quick Answer: 223

    Detailed Answer: 231

  • Which observation in the newborn of a diabetic mother would require immediate nursing intervention?

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    Crying

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    Wakefulness

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    Jitteriness

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    Yawning

    Quick Answer: 223

    Detailed Answer: 231

  • The nurse caring for a client receiving intravenous magnesium sulfate must closely observe for side effects associated with drug therapy. An expected side effect of magnesium sulfate is:

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    Decreased urinary output

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    Hypersomnolence

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    Absence of knee jerk reflex

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    Decreased respiratory rate

    Quick Answer: 223

    Detailed Answer: 231

  • The client has elected to have epidural anesthesia to relieve labor pain. If the client experiences hypotension, the nurse would:

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    Place her in Trendelenburg position.

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    Decrease the rate of IV infusion.

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    Administer oxygen per nasal cannula.

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    Increase the rate of the IV infusion.

    Quick Answer: 223

    Detailed Answer: 231

  • A client has cancer of the pancreas. The nurse should be most concerned about which nursing diagnosis?

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    Alteration in nutrition

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    Alteration in bowel elimination

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    Alteration in skin integrity

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    Ineffective individual coping

    Quick Answer: 223

    Detailed Answer: 231

  • The nurse is caring for a client with uremic frost. The nurse is aware that uremic frost is often seen in clients with:

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    Severe anemia

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    Arteriosclerosis

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    Liver failure

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    Parathyroid disorder

    Quick Answer: 223

    Detailed Answer: 231

  • The client arrives in the emergency department after a motor vehicle accident. Nursing assessment findings include BP 80/34, pulse rate 120, and respirations 20. Which is the client’s most appropriate priority nursing diagnosis?

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    Alteration in cerebral tissue perfusion

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    Fluid volume deficit

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    Ineffective airway clearance

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    Alteration in sensory perception

    Quick Answer: 223

    Detailed Answer: 231

  • The home health nurse is visiting an 18-year-old with osteogenesis imperfecta. Which information obtained on the visit would cause the most concern? The client:

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    Likes to play football

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    Drinks carbonated drinks

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    Has two sisters

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    Is taking acetaminophen for pain

    Quick Answer: 223

    Detailed Answer: 231

  • The nurse working the organ transplant unit is caring for a client with a white blood cell count of 450. During evening visitation, a visitor brings a basket of fruit. What action should the nurse take?

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    Allow the client to keep the fruit.

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    Place the fruit next to the bed for easy access by the client.

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    Offer to wash the fruit for the client.

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    Ask the family members to take the fruit home.

    Quick Answer: 223

    Detailed Answer: 231

  • The nurse is caring for the client following a laryngectomy when suddenly the client becomes nonresponsive and pale, with a BP of 90/40. The initial nurse’s action should be to:

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    Place the client in Trendelenburg position.

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    Increase the infusion of normal saline.

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    Administer atropine intravenously.

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    Move the emergency cart to the bedside.

    Quick Answer: 223

    Detailed Answer: 231

  • The client admitted two days earlier with a lung resection accidentally pulls out the chest tube. Which action by the nurse indicates understanding of the management of chest tubes?

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    Order a chest x-ray.

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    Reinsert the tube.

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    Cover the insertion site with a Vaseline gauze.

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    Call the doctor.

    Quick Answer: 223

    Detailed Answer: 231

  • A client being treated with sodium warfarin (Coumadin) has a Protime of 120 seconds. Which intervention would be most important to include in the nursing care plan?

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    Assess for signs of abnormal bleeding.

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    Anticipate an increase in the Coumadin dosage.

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    Instruct the client regarding the drug therapy.

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    Increase the frequency of neurological assessments.

    Quick Answer: 223

    Detailed Answer: 231

  • Which selection would provide the most calcium for the client who is four months pregnant?

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    A granola bar

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    A bran muffin

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    A cup of yogurt

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    A glass of fruit juice

    Quick Answer: 223

    Detailed Answer: 232

  • The client with preeclampsia is admitted to the unit with an order for magnesium sulfate. Which action by the nurse indicates the understanding of magnesium toxicity?

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    The nurse performs a vaginal exam every 30 minutes.

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    The nurse places a padded tongue blade at the bedside.

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    The nurse inserts a Foley catheter.

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    The nurse darkens the room.

    Quick Answer: 223

    Detailed Answer: 232

  • The best size cathlon for administration of a blood transfusion to a six-year-old is:

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    18 gauge

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    19 gauge

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    22 gauge

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    20 gauge

    Quick Answer: 223

    Detailed Answer: 232

  • A client is admitted to the unit two hours after an explosion causes burns to the face. The nurse would be most concerned with the client developing which of the following?

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    Hypovolemia

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    Laryngeal edema

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    Hypernatremia

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    Hyperkalemia

    Quick Answer: 223

    Detailed Answer: 232

  • The client has recently been diagnosed with diabetes. Which of the following indicates understanding of the management of diabetes?

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    The client selects a balanced diet from the menu.

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    The client can tell the nurse the normal blood glucose level.

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    The client asks for brochures on the subject of diabetes.

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    The client demonstrates correct insulin injection technique.

    Quick Answer: 223

    Detailed Answer: 232

  • The client is admitted following cast application for a fractured ulna. Which finding should be reported to the doctor?

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    Pain at the site

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    Warm fingers

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    Pulses rapid

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    Paresthesia of the fingers

    Quick Answer: 223

    Detailed Answer: 232

  • The client with AIDS should be taught to:

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    Avoid warm climates.

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    Refrain from taking herbals.

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    Avoid exercising.

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    Report any changes in skin color.

    Quick Answer: 223

    Detailed Answer: 232

  • Which action by the healthcare worker indicates a need for further teaching?

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    The nursing assistant ambulates the elderly client using a gait belt.

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    The nurse wears goggles while performing a veno-puncture.

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    The nurse washes his hands after changing a dressing.

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    The nurse wears gloves to monitor the IV infusion rate.

    Quick Answer: 223

    Detailed Answer: 232

  • The client is having electroconvulsive therapy for treatment of severe depression. Prior to the ECT, the nurse should:

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    Apply a tourniquet to the client’s arm.

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    Administer an anticonvulsant medication.

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    Ask the client if he is allergic to shellfish.

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    Apply a blood pressure cuff to the arm.

    Quick Answer: 223

    Detailed Answer: 232

  • The five-year-old is being tested for enterobiasis (pinworms). Which symptom is associated with enterobiasis?

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    Rectal itching

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    Nausea

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    Oral ulcerations

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    Scalp itching

    Quick Answer: 223

    Detailed Answer: 232

  • The nurse is teaching the mother regarding treatment for pedicalosis capitis. Which instruction should be given regarding the medication?

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    Treatment is not recommended for children less than 10 years of age.

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    Bed linens should be washed in hot water.

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    Medication therapy will continue for one year.

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    Intravenous antibiotic therapy will be ordered.

    Quick Answer: 223

    Detailed Answer: 232

  • The registered nurse is making assignments for the day. Which client should be assigned to the pregnant nurse?

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    The client with HIV

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    The client with a radium implant for cervical cancer

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    The client with RSV (respiratory synctial virus)

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    The client with cytomegalovirus

    Quick Answer: 223

    Detailed Answer: 232

  • The nurse is planning room assignments for the day. Which client should be assigned to a private room if only one is available?

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    The client with methicillin resistant-staphylococcus aureas (MRSA)

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    The client with diabetes

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    The client with pancreatitis

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    The client with Addison’s disease

    Quick Answer: 223

    Detailed Answer: 232

  • The doctor accidentally cuts the bowel during surgery. As a result of this action, the client develops an infection and suffers brain damage. The doctor can be charged with:

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    Negligence

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    Tort

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    Assault

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    Malpractice

    Quick Answer: 223

    Detailed Answer: 233

  • Which assignment should not be performed by the nursing assistant?

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    Feeding the client

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    Bathing the client

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    Obtaining a stool

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    Administering a fleet enema

    Quick Answer: 223

    Detailed Answer: 233

  • The mother calls the clinic to report that her newborn has a rash on his forehead and face. Which action is most appropriate?

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    Tell the mother to wash the face with soap and apply powder.

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    Tell her that 30% of newborns have a rash that will go away by one month of life.

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    Report the rash to the doctor immediately.

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    Ask the mother if anyone else in the family has had a rash in the last six months.

    Quick Answer: 223

    Detailed Answer: 233

  • Which nurse should not be assigned to care for the client with a radium implant for vaginal cancer?

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    The LPN who is six months postpartum

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    The RN who is pregnant

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    The RN who is allergic to iodine

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    The RN with a three-year-old at home

    Quick Answer: 223

    Detailed Answer: 233

  • Which information should be reported to the state Board of Nursing?

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    The facility fails to provide literature in both Spanish and English.

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    The narcotic count has been incorrect on the unit for the past three days.

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    The client fails to receive an itemized account of his bills and services received during his hospital stay.

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    The nursing assistant assigned to the client with hepatitis fails to feed the client and give the bath.

    Quick Answer: 223

    Detailed Answer: 233

  • The nurse is suspected of charting medication administration that he did not give. After talking to the nurse, the charge nurse should:

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    Call the Board of Nursing.

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    File a formal reprimand.

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    Terminate the nurse.

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    Charge the nurse with a tort.

    Quick Answer: 223

    Detailed Answer: 233

  • The home health nurse is planning for the day’s visits. Which client should be seen first?

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    The 78-year-old who had a gastrectomy three weeks ago and has a PEG tube

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    The five-month-old discharged one week ago with pneumonia who is being treated with amoxicillin liquid suspension

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    The 50-year-old with MRSA being treated with Vancomycin via a PICC line

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    The 30-year-old with an exacerbation of multiple sclerosis being treated with cortisone via a centrally placed venous catheter

    Quick Answer: 223

    Detailed Answer: 233

  • The emergency room is flooded with clients injured in a tornado. Which clients can be assigned to share a room in the emergency department during the disaster?

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    A client having auditory hallucinations and the client with ulcerative colitis

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    The client who is pregnant and the client with a broken arm

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    A child who is cyanotic with severe dypsnea and a client with a frontal head injury

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    The client who arrives with a large puncture wound to the abdomen and the client with chest pain

    Quick Answer: 223

    Detailed Answer: 233

  • Before administering eardrops to a toddler, the nurse should recognize that it is essential to consider which of the following?

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    The age of the child

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    The child’s weight

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    The developmental level of the child

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    The IQ of the child

    Quick Answer: 223

    Detailed Answer: 233

  • The nurse is discussing meal planning with the mother of a two-year-old. Which of the following statements, if made by the mother, would require a need for further instruction?

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    “It is okay to give my child white grape juice for breakfast.”

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    “My child can have a grilled cheese sandwich for lunch.”

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    “We are going on a camping trip this weekend, and I have bought hot dogs to grill for his lunch.”

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    “For a snack, my child can have ice cream.”

    Quick Answer: 223

    Detailed Answer: 233

  • A client with AIDS has a viral load of 200 copies per ml. The nurse should interpret this finding as:

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    The client is at risk for opportunistic diseases.

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    The client is no longer communicable.

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    The client’s viral load is extremely low so he is relatively free of circulating virus.

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    The client’s T-cell count is extremely low.

    Quick Answer: 223

    Detailed Answer: 233

  • The client has an order for sliding scale insulin at 1900 hours and Lantus insulin at the same hour. The nurse should:

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    Administer the two medications together.

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    Administer the medications in two injections.

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    Draw up the Lantus insulin and then the regular insulin and administer them together.

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    Contact the doctor because these medications should not be given to the same client.

    Quick Answer: 223

    Detailed Answer: 234

  • A priority nursing diagnosis for a child being admitted from surgery following a tonsillectomy is:

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    Altered nutrition

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    Impaired communication

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    Risk for injury/aspiration

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    Altered urinary elimination

    Quick Answer: 223

    Detailed Answer: 234

  • What would the nurse expect the admitting assessment to reveal in a client with glomerulonephritis?

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    Hypertension

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    Lassitude

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    Fatigue

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    Vomiting and diarrhea

    Quick Answer: 223

    Detailed Answer: 234

  • Which action is contraindicated in the client with epiglottis?

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    Ambulation

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    Oral airway assessment using a tongue blade

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    Placing a blood pressure cuff on the arm

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    Checking the deep tendon reflexes.

    Quick Answer: 223

    Detailed Answer: 234

  • A 25-year-old client with a goiter is admitted to the unit. What would the nurse expect the admitting assessment to reveal?

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    Slow pulse

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    Anorexia

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    Bulging eyes

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    Weight gain

    Quick Answer: 223

    Detailed Answer: 234

  • Which of the following foods, if selected by the mother with a child with celiac, would indicate her understanding of the dietary instructions?

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    Whole-wheat toast

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    Angel hair pasta

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    Reuben on rye

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    Rice cereal

    Quick Answer: 223

    Detailed Answer: 234

  • The first action that the nurse should take if she finds the client has an O2 saturation of 68% is:

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    Elevate the head.

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    Recheck the O2 saturation in 30 minutes.

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    Apply oxygen by mask.

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    Assess the heart rate.

    Quick Answer: 223

    Detailed Answer: 234

  • Which observation would the nurse expect to make after an amniotomy?

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    Dark yellow amniotic fluid

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    Clear amniotic fluid

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    Greenish amniotic fluid

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    Red amniotic fluid

    Quick Answer: 223

    Detailed Answer: 234

  • The client taking Glyburide (Diabeta) should be cautioned to:

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    Avoid eating sweets.

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    Report changes in urinary pattern.

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    Allow three hours for onset.

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    Check the glucose daily.

    Quick Answer: 223

    Detailed Answer: 234

  • The obstetric client’s fetal heart rate is 80–90 during the contractions. The first action the nurse should take is:

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    Reposition the monitor.

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    Turn the client to her left side.

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    Ask the client to ambulate.

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    Prepare the client for delivery.

    Quick Answer: 223

    Detailed Answer: 234

  • Arterial ulcers are best described as ulcers that:

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    Are smooth in texture

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    Have irregular borders

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    Are cool to touch

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    Are painful to touch

    Quick Answer: 223

    Detailed Answer: 234

  • A vaginal exam reveals a footling breech presentation. The nurse should take which of the following actions at this time?

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    Anticipate the need for a Caesarean section.

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    Apply an internal fetal monitor.

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    Place the client in Genu Pectoral position.

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    Perform an ultrasound.

    Quick Answer: 223

    Detailed Answer: 234

  • A vaginal exam reveals that the cervix is 4cm dilated, with intact membranes and a fetal heart tone rate of 160–170bpm. The nurse decides to apply an external fetal monitor. The rationale for this implementation is:

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    The cervix is closed.

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    The membranes are still intact.

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    The fetal heart tones are within normal limits.

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    The contractions are intense enough for insertion of an internal monitor.

    Quick Answer: 223

    Detailed Answer: 234

  • The following are all nursing diagnoses appropriate for a gravida 1 para 0 in labor. Which one would be most appropriate for the primagravida as she completes the early phase of labor?

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    Impaired gas exchange related to hyperventilation

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    Alteration in placental perfusion related to maternal position

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    Impaired physical mobility related to fetal-monitoring equipment

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    Potential fluid volume deficit related to decreased fluid intake

    Quick Answer: 223

    Detailed Answer: 235

  • As the client reaches 6cm dilation, the nurse notes late decelerations on the fetal monitor. What is the most likely explanation of this pattern?

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    The baby is sleeping.

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    The umbilical cord is compressed.

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    There is head compression.

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    There is uteroplacental insufficiency.

    Quick Answer: 223

    Detailed Answer: 235

  • The nurse notes variable decelerations on the fetal monitor strip. The most appropriate initial action would be to:

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    Notify her doctor.

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    Start an IV.

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    Reposition the client.

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    Readjust the monitor.

    Quick Answer: 223

    Detailed Answer: 235

  • Which of the following is a characteristic of an ominous periodic change in the fetal heart rate?

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    A fetal heart rate of 120–130bpm

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    A baseline variability of 6–10bpm

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    Accelerations in FHR with fetal movement

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    A recurrent rate of 90–100bpm at the end of the contractions

    Quick Answer: 223

    Detailed Answer: 235

  • The rationale for inserting a French catheter every hour for the client with epidural anesthesia is:

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    The bladder fills more rapidly because of the medication used for the epidural.

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    Her level of consciousness is such that she is in a trancelike state.

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    The sensation of the bladder filling is diminished or lost.

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    She is embarrassed to ask for the bedpan that frequently.

    Quick Answer: 223

    Detailed Answer: 235

  • A client in the family planning clinic asks the nurse about the most likely time for her to conceive. The nurse explains that conception is most likely to occur when:

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    Estrogen levels are low

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    Lutenizing hormone is high

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    The endometrial lining is thin

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    The progesterone level is low

    Quick Answer: 223

    Detailed Answer: 235

  • A client tells the nurse that she plans to use the rhythm method of birth control. The nurse is aware that the success of the rhythm method depends on the:

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    Age of the client

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    Frequency of intercourse

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    Regularity of the menses

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    Range of the client’s temperature

    Quick Answer: 223

    Detailed Answer: 235

  • A client with diabetes asks the nurse for advice regarding methods of birth control. Which method of birth control is most suitable for the client with diabetes?

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    Intrauterine device

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    Oral contraceptives

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    Diaphragm

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    Contraceptive sponge

    Quick Answer: 223

    Detailed Answer: 235

  • The doctor suspects that the client has an ectopic pregnancy. Which symptom is consistent with a diagnosis of a ruptured ectopic pregnancy?

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    Painless vaginal bleeding

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    Abdominal cramping

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    Throbbing pain in the upper quadrant

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    Sudden, stabbing pain in the lower quadrant

    Quick Answer: 223

    Detailed Answer: 235

  • The nurse is teaching a pregnant client about nutritional needs during pregnancy. Which menu selection will best meet the nutritional needs of the pregnant client?

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    Hamburger patty, green beans, French fries, and iced tea

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    Roast beef sandwich, potato chips, baked beans, and cola

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    Baked chicken, fruit cup, potato salad, coleslaw, yogurt, and iced tea

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    Fish sandwich, gelatin with fruit, and coffee

    Quick Answer: 223

    Detailed Answer: 236

  • The client with hyperemesis gravidarum is at risk for developing:

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    Respiratory alkalosis without dehydration

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    Metabolic acidosis with dehydration

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    Respiratory acidosis without dehydration

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    Metabolic alkalosis with dehydration

    Quick Answer: 223

    Detailed Answer: 236

  • A client tells the doctor that she is about 20 weeks pregnant. The most definitive sign of pregnancy is:

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    Elevated human chorionic gonadatropin

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    The presence of fetal heart tones

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    Uterine enlargement

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    Breast enlargement and tenderness

    Quick Answer: 223

    Detailed Answer: 236

  • The nurse is caring for a neonate whose mother is diabetic. The nurse will expect the neonate to be:

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    Hypoglycemic, small for gestational age

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    Hyperglycemic, large for gestational age

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    Hypoglycemic, large for gestational age

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    Hyperglycemic, small for gestational age

    Quick Answer: 223

    Detailed Answer: 236

  • Which of the following instructions should be included in the nurse’s teaching regarding oral contraceptives?

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    Weight gain should be reported to the physician.

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    An alternate method of birth control is needed when taking antibiotics.

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    If the client misses one or more pills, two pills should be taken per day for one week.

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    Changes in the menstrual flow should be reported to the physician.

    Quick Answer: 223

    Detailed Answer: 236

  • The nurse is discussing breastfeeding with a postpartum client. Breastfeeding is contraindicated in the postpartum client with:

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    Diabetes

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    HIV

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    Hypertension

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    Thyroid disease

    Quick Answer: 224

    Detailed Answer: 236

  • A client is admitted to the labor and delivery unit complaining of vaginal bleeding with very little discomfort. The nurse’s first action should be to:

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    Assess the fetal heart tones.

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    Check for cervical dilation.

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    Check for firmness of the uterus.

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    Obtain a detailed history.

    Quick Answer: 224

    Detailed Answer: 236

  • A client telephones the emergency room stating that she thinks that she is in labor. The nurse should tell the client that labor has probably begun when:

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    Her contractions are two minutes apart.

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    She has back pain and a bloody discharge.

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    She experiences abdominal pain and frequent urination.

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    Her contractions are five minutes apart.

    Quick Answer: 224

    Detailed Answer: 236

  • The nurse is teaching a group of prenatal clients about the effects of cigarette smoke on fetal development. Which characteristic is associated with babies born to mothers who smoked during pregnancy?

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    Low birth weight

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    Large for gestational age

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    Preterm birth, but appropriate size for gestation

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    Growth retardation in weight and length

    Quick Answer: 224

    Detailed Answer: 237

  • The physician has ordered an injection of RhoGam for the postpartum client whose blood type is A negative but whose baby is O positive. To provide postpartum prophylaxis, RhoGam should be administered:

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    Within 72 hours of delivery

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    Within one week of delivery

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    Within two weeks of delivery

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    Within one month of delivery

    Quick Answer: 224

    Detailed Answer: 237

  • After the physician performs an amniotomy, the nurse’s first action should be to assess the:

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    Degree of cervical dilation

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    Fetal heart tones

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    Client’s vital signs

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    Client’s level of discomfort

    Quick Answer: 224

    Detailed Answer: 237

  • A client is admitted to the labor and delivery unit. The nurse performs a vaginal exam and determines that the client’s cervix is 5cm dilated with 75% effacement. Based on the nurse’s assessment, the client is in which phase of labor?

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    Active

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    Latent

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    Transition

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    Early

    Quick Answer: 224

    Detailed Answer: 237

  • A newborn with narcotic abstinence syndrome is admitted to the nursery. Nursing care of the newborn should include:

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    Teaching the mother to provide tactile stimulation

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    Wrapping the newborn snugly in a blanket

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    Placing the newborn in the infant seat

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    Initiating an early infant-stimulation program

    Quick Answer: 224

    Detailed Answer: 237

  • A client elects to have epidural anesthesia to relieve the discomfort of labor. Following the initiation of epidural anesthesia, the nurse should give priority to:

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    Checking for cervical dilation

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    Placing the client in a supine position

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    Checking the client’s blood pressure

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    Obtaining a fetal heart rate

    Quick Answer: 224

    Detailed Answer: 237

  • The nurse is aware that the best way to prevent post-operative wound infection in the surgical client is to:

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    Administer a prescribed antibiotic.

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    Wash her hands for two minutes before care.

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    Wear a mask when providing care.

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    Ask the client to cover her mouth when she coughs.

    Quick Answer: 224

    Detailed Answer: 237

  • The elderly client is admitted to the emergency room. Which symptom is the client with a fractured hip most likely to exhibit?

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    Pain

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    Disalignment

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    Cool extremity

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    Absence of pedal pulses

    Quick Answer: 224

    Detailed Answer: 237

  • The nurse knows that a 60-year-old female client’s susceptibility to osteoporosis is most likely related to:

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    Lack of exercise

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    Hormonal disturbances

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    Lack of calcium

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    Genetic predisposition

    Quick Answer: 224

    Detailed Answer: 237

  • A two-year-old is admitted for repair of a fractured femur and is placed in Bryant’s traction. Which finding by the nurse indicates that the traction is working properly?

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    The infant no longer complains of pain.

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    The buttocks are 15° off the bed.

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    The legs are suspended in the traction.

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    The pins are secured within the pulley.

    Quick Answer: 224

    Detailed Answer: 238

  • Which statement is true regarding balanced skeletal traction? Balanced skeletal traction:

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    Uses a Steinman pin

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    Requires that both legs be secured

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    Utilizes Kirschner wires

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    Is used primarily to heal the fractured hips

    Quick Answer: 224

    Detailed Answer: 238

  • The client is admitted for an open reduction internal fixation of a fractured hip. Immediately following surgery, the nurse should give priority to assessing the:

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    Serum collection (Davol) drain

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    Client’s pain

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    Nutritional status

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    Immobilizer

    Quick Answer: 224

    Detailed Answer: 238

  • Which statement made by the family member caring for the client with a percutaneous gastrostomy tube indicates understanding of the nurse’s teaching?

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    “I must flush the tube with water after feedings and clamp the tube.”

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    “I must check placement four times per day.”

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    “I will report to the doctor any signs of indigestion.”

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    “If my father is unable to swallow, I will discontinue the feeding and call the clinic.”

    Quick Answer: 224

    Detailed Answer: 238

  • The nurse is assessing the client with a total knee replacement two hours post-operative. Which information requires notification of the doctor?

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    Scant bleeding on the dressing

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    Low-grade temperature

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    Hemoglobin of 7gm

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    The urinary output has been 120ml during the last hour

    Quick Answer: 224

    Detailed Answer: 238

  • The nurse is caring for the client with a five-year-old diagnosis of plumbism. Which information in the health history is most likely related to the development of plumbism?

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    The client has traveled out of the country in the last six months.

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    The client’s parents are skilled stained-glass artists.

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    The client lives in a house built in 1990.

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    The client has several brothers and sisters.

    Quick Answer: 224

    Detailed Answer: 238

  • A client with a total hip replacement requires special equipment. Which equipment would assist the client with a total hip replacement with activities of daily living?

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    High-seat commode

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    Recliner

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    TENS unit

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    Abduction pillow

    Quick Answer: 224

    Detailed Answer: 238

  • An elderly client with an abdominal surgery is admitted to the unit following surgery. In anticipation of complications of anesthesia and narcotic administration, the nurse should:

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    Administer oxygen via nasal cannula.

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    Have narcan (naloxane) available.

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    Prepare to administer blood products.

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    Prepare to do cardioresuscitation.

    Quick Answer: 224

    Detailed Answer: 238

  • Which roommate would be most suitable for the six-year-old male with a fractured femur in Russell’s traction?

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    16-year-old female with scoliosis

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    12-year-old male with a fractured femur

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    10-year-old male with sarcoma

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    6-year-old male with osteomylitis

    Quick Answer: 224

    Detailed Answer: 239

  • A client with osteoarthritis has a prescription for Celebrex (celecoxib). Which instruction should be included in the discharge teaching?

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    Take the medication with milk.

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    Report chest pain.

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    Remain upright after taking for 30 minutes.

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    Allow six weeks for optimal effects.

    Quick Answer: 224

    Detailed Answer: 239

  • A client with a fractured tibia has a plaster-of-Paris cast applied to immobilize the fracture. Which action by the nurse indicates understanding of a plaster-of-Paris cast? The nurse:

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    Handles the cast with the fingertips

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    Petals the cast

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    Dries the cast with a hair dryer

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    Allows 24 hours before bearing weight

    Quick Answer: 224

    Detailed Answer: 239

  • The teenager with a fiberglass cast asks the nurse if it will be okay to allow his friends to autograph his cast. Which response would be best?

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    “It will be alright for your friends to autograph the cast.”

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    “Because the cast is made of plaster, autographing can weaken the cast.”

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    “If they don’t use chalk to autograph, it is okay.”

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    “Autographing or writing on the cast in any form will harm the cast.”

    Quick Answer: 224

    Detailed Answer: 239

  • The nurse is assigned to care for the client with a Steinman pin. During pin care, she notes that the LPN uses sterile gloves and Q-tips to clean the pin. Which action should the nurse take at this time?

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    Assisting the LPN with opening sterile packages and peroxide

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    Telling the LPN that clean gloves are allowed

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    Telling the LPN that the registered nurse should perform pin care

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    Asking the LPN to clean the weights and pulleys with peroxide

    Quick Answer: 224

    Detailed Answer: 239

  • A child with scoliosis has a spica cast applied. Which action specific to the spica cast should be taken?

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    Check the bowel sounds.

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    Assess the blood pressure.

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    Offer pain medication.

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    Check for swelling.

    Quick Answer: 224

    Detailed Answer: 239

  • The client with a cervical fracture is placed in traction. Which type of traction will be utilized at the time of discharge?

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    Russell’s traction

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    Buck’s traction

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    Halo traction

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    Crutchfield tong traction

    Quick Answer: 224

    Detailed Answer: 239

  • A client with a total knee replacement has a CPM (continuous passive motion device) applied during the post-operative period. Which statement made by the nurse indicates understanding of the CPM machine?

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    “Use of the CPM will permit the client to ambulate during the therapy.”

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    “The CPM machine controls should be positioned distal to the site.”

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    “If the client complains of pain during the therapy, I will turn off the machine and call the doctor.”

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    “Use of the CPM machine will alleviate the need for physical therapy after the client is discharged.”

    Quick Answer: 224

    Detailed Answer: 239

  • A client with a fractured hip is being taught correct use of the walker. The nurse is aware that the correct use of the walker is achieved if the:

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    Palms rest lightly on the handles

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    Elbows are flexed 0°

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    Client walks to the front of the walker

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    Client carries the walker

    Quick Answer: 224

    Detailed Answer: 240

  • When assessing a laboring client, the nurse finds a prolapsed cord. The nurse should:

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    Attempt to replace the cord.

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    Place the client on her left side.

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    Elevate the client’s hips.

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    Cover the cord with a dry, sterile gauze.

    Quick Answer: 224

    Detailed Answer: 240

  • The nurse is caring for a 30-year-old male admitted with a stab wound. While in the emergency room, a chest tube is inserted. Which of the following explains the primary rationale for insertion of chest tubes?

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    The tube will allow for equalization of the lung expansion.

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    Chest tubes serve as a method of draining blood and serous fluid and assist in reinflating the lungs.

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    Chest tubes relieve pain associated with a collapsed lung.

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    Chest tubes assist with cardiac function by stabilizing lung expansion.

    Quick Answer: 224

    Detailed Answer: 240

  • A client who delivered this morning tells the nurse that she plans to breastfeed her baby. The nurse is aware that successful breastfeeding is most dependent on the:

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    Mother’s educational level

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    Infant’s birth weight

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    Size of the mother’s breast

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    Mother’s desire to breastfeed

    Quick Answer: 224

    Detailed Answer: 240

  • The nurse is monitoring the progress of a client in labor. Which finding should be reported to the physician immediately?

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    The presence of scant bloody discharge

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    Frequent urination

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    The presence of green-tinged amniotic fluid

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    Moderate uterine contractions

    Quick Answer: 224

    Detailed Answer: 240

  • The nurse is measuring the duration of the client’s contractions. Which statement is true regarding the measurement of the duration of contractions?

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    Duration is measured by timing from the beginning of one contraction to the beginning of the next contraction.

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    Duration is measured by timing from the end of one contraction to the beginning of the next contraction.

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    Duration is measured by timing from the beginning of one contraction to the end of the same contraction.

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    Duration is measured by timing from the peak of one contraction to the end of the same contraction.

    Quick Answer: 224

    Detailed Answer: 240

  • The physician has ordered an intravenous infusion of Pitocin for the induction of labor. When caring for the obstetric client receiving intravenous Pitocin, the nurse should monitor for:

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    Maternal hypoglycemia

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    Fetal bradycardia

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    Maternal hyperreflexia

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    Fetal movement

    Quick Answer: 224

    Detailed Answer: 240

  • A client with diabetes visits the prenatal clinic at 28 weeks gestation. Which statement is true regarding insulin needs during pregnancy?

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    Insulin requirements moderate as the pregnancy progresses.

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    A decreased need for insulin occurs during the second trimester.

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    Elevations in human chorionic gonadotrophin decrease the need for insulin.

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    Fetal development depends on adequate insulin regulation.

    Quick Answer: 224

    Detailed Answer: 240

  • A client in the prenatal clinic is assessed to have a blood pressure of 180/96. The nurse should give priority to:

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    Providing a calm environment

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    Obtaining a diet history

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    Administering an analgesic

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    Assessing fetal heart tones

    Quick Answer: 224

    Detailed Answer: 240

  • A primigravida, age 42, is six weeks pregnant. Based on the client’s age, her infant is at risk for:

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    Down syndrome

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    Respiratory distress syndrome

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    Turner’s syndrome

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    Pathological jaundice

    Quick Answer: 224

    Detailed Answer: 241

  • A client with a missed abortion at 29 weeks gestation is admitted to the hospital. The client will most likely be treated with:

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    Magnesium sulfate

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    Calcium gluconate

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    Dinoprostone (Prostin E.)

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    Bromocrystine (Parlodel)

    Quick Answer: 224

    Detailed Answer: 241

  • A client with preeclampsia has been receiving an infusion containing magnesium sulfate for a blood pressure that is 160/80; deep tendon reflexes are 1 plus, and the urinary output for the past hour is 100mL. The nurse should:

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    Continue the infusion of magnesium sulfate while monitoring the client’s blood pressure.

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    Stop the infusion of magnesium sulfate and contact the physician.

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    Slow the infusion rate and turn the client on her left side.

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    Administer calcium gluconate IV push and continue to monitor the blood pressure.

    Quick Answer: 224

    Detailed Answer: 241

  • Which statement made by the nurse describes the inheritance pattern of autosomal recessive disorders?

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    An affected newborn has unaffected parents.

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    An affected newborn has one affected parent.

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    Affected parents have a one in four chance of passing on the defective gene.

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    Affected parents have unaffected children who are carriers.

    Quick Answer: 224

    Detailed Answer: 241

  • A pregnant client, age 32, asks the nurse why her doctor has recommended a serum alpha fetoprotein. The nurse should explain that the doctor has recommended the test:

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    Because it is a state law

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    To detect cardiovascular defects

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    Because of her age

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    To detect neurological defects

    Quick Answer: 224

    Detailed Answer: 241

  • A client with hypothyroidism asks the nurse if she will still need to take thyroid medication during the pregnancy. The nurse’s response is based on the knowledge that:

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    There is no need to take thyroid medication because the fetus’s thyroid produces a thyroid-stimulating hormone.

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    Regulation of thyroid medication is more difficult because the thyroid gland increases in size during pregnancy.

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    It is more difficult to maintain thyroid regulation during pregnancy due to a slowing of metabolism.

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    Fetal growth is arrested if thyroid medication is continued during pregnancy.

    Quick Answer: 224

    Detailed Answer: 241

  • The nurse is responsible for performing a neonatal assessment on a full-term infant. At one minute, the nurse could expect to find:

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    An apical pulse of 100

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    An absence of tonus

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    Cyanosis of the feet and hands

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    Jaundice of the skin and sclera

    Quick Answer: 224

    Detailed Answer: 241

  • A client with sickle cell anemia is admitted to the labor and delivery unit during the first phase of labor. The nurse should anticipate the client’s need for:

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    Supplemental oxygen

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    Fluid restriction

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    Blood transfusion

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    Delivery by Caesarean section

    Quick Answer: 224

    Detailed Answer: 241

  • A client with diabetes has an order for ultrasonography. Preparation for an ultrasound includes:

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    Increasing fluid intake

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    Limiting ambulation

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    Administering an enema

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    Withholding food for eight hours

    Quick Answer: 224

    Detailed Answer: 241

  • An infant who weighs 8 pounds at birth would be expected to weigh how many pounds at one year?

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    14 pounds

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    16 pounds

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    18 pounds

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    24 pounds

    Quick Answer: 224

    Detailed Answer: 241

  • A pregnant client with a history of alcohol addiction is scheduled for a nonstress test. The nonstress test:

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    Determines the lung maturity of the fetus

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    Measures the activity of the fetus

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    Shows the effect of contractions on the fetal heart rate

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    Measures the neurological well-being of the fetus

    Quick Answer: 224

    Detailed Answer: 242

  • A full-term male has hypospadias. Which statement describes hypospadias?

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    The urethral opening is absent

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    The urethra opens on the top side of the penis

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    The urethral opening is enlarged

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    The urethra opens on the under side of the penis

    Quick Answer: 224

    Detailed Answer: 242

  • A gravida III para II is admitted to the labor unit. Vaginal exam reveals that the client’s cervix is 8cm dilated, with complete effacement. The priority nursing diagnosis at this time is:

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    Alteration in coping related to pain

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    Potential for injury related to precipitate delivery

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    Alteration in elimination related to anesthesia

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    Potential for fluid volume deficit related to NPO status

    Quick Answer: 224

    Detailed Answer: 242

  • The client with varicella will most likely have an order for which category of medication?

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    Antibiotics

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    Antipyretics

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    Antivirals

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    Anticoagulants

    Quick Answer: 224

    Detailed Answer: 242

  • A client is admitted complaining of chest pain. Which of the following drug orders should the nurse question?

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    Nitroglycerin

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    Ampicillin

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    Propranolol

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    Verapamil

    Quick Answer: 224

    Detailed Answer: 242

  • Which of the following instructions should be included in the teaching for the client with rheumatoid arthritis?

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    Avoid exercise because it fatigues the joints.

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    Take prescribed anti-inflammatory medications with meals.

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    Alternate hot and cold packs to affected joints.

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    Avoid weight-bearing activity.

    Quick Answer: 224

    Detailed Answer: 242

  • A client with acute pancreatitis is experiencing severe abdominal pain. Which of the following orders should be questioned by the nurse?

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    Meperidine 100mg IM m 4 hours PRN pain

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    Mylanta 30 ccs m 4 hours via NG

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    Cimetadine 300mg PO m.i.d.

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    Morphine 8mg IM m 4 hours PRN pain

    Quick Answer: 224

    Detailed Answer: 242

  • The client is admitted to the chemical dependence unit with an order for continuous observation. The nurse is aware that the doctor has ordered continuous observation because:

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    Hallucinogenic drugs create both stimulant and depressant effects.

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    Hallucinogenic drugs induce a state of altered perception.

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    Hallucinogenic drugs produce severe respiratory depression.

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    Hallucinogenic drugs induce rapid physical dependence.

    Quick Answer: 224

    Detailed Answer: 242

  • A client with a history of abusing barbiturates abruptly stops taking the medication. The nurse should give priority to assessing the client for:

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    Depression and suicidal ideation

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    Tachycardia and diarrhea

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    Muscle cramping and abdominal pain

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    Tachycardia and euphoric mood

    Quick Answer: 224

    Detailed Answer: 242

  • During the assessment of a laboring client, the nurse notes that the FHT are loudest in the upper-right quadrant. The infant is most likely in which position?

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    Right breech presentation

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    Right occipital anterior presentation

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    Left sacral anterior presentation

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    Left occipital transverse presentation

    Quick Answer: 224

    Detailed Answer: 243

  • The primary physiological alteration in the development of asthma is:

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    Bronchiolar inflammation and dyspnea

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    Hypersecretion of abnormally viscous mucus

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    Infectious processes causing mucosal edema

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    Spasm of bronchiolar smooth muscle

    Quick Answer: 224

    Detailed Answer: 243

  • A client with mania is unable to finish her dinner. To help her maintain sufficient nourishment, the nurse should:

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    Serve high-calorie foods she can carry with her.

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    Encourage her appetite by sending out for her favorite foods.

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    Serve her small, attractively arranged portions.

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    Allow her in the unit kitchen for extra food whenever she pleases.

    Quick Answer: 224

    Detailed Answer: 243

  • To maintain Bryant’s traction, the nurse must make certain that the child’s:

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    Hips are resting on the bed, with the legs suspended at a right angle to the bed

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    Hips are slightly elevated above the bed and the legs are suspended at a right angle to the bed

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    Hips are elevated above the level of the body on a pillow and the legs are suspended parallel to the bed

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    Hips and legs are flat on the bed, with the traction positioned at the foot of the bed

    Quick Answer: 224

    Detailed Answer: 243

  • Which action by the nurse indicates understanding of herpes zoster?

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    The nurse covers the lesions with a sterile dressing.

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    The nurse wears gloves when providing care.

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    The nurse administers a prescribed antibiotic.

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    The nurse administers oxygen.

    Quick Answer: 224

    Detailed Answer: 243

  • There is an order for a trough to be drawn on the client receiving Vancomycin. The nurse is aware that he should contact the lab for them to collect the blood:

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    15 minutes after the infusion

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    30 minutes before the fourth infusion

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    One hour after the infusion

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    Two hours after the infusion

    Quick Answer: 224

    Detailed Answer: 243

  • The client using a diaphragm should be instructed to:

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    Refrain from keeping the diaphragm in longer than four hours

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    Keep the diaphragm in a cool location

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    Have the diaphragm resized if she gains five pounds

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    Have the diaphragm resized if she has any surgery

    Quick Answer: 224

    Detailed Answer: 243

  • The nurse is providing postpartum teaching for a mother planning to breastfeed her infant. Which of the client’s statements indicates the need for additional teaching?

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    “I’m wearing a support bra.”

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    “I’m expressing milk from my breast.”

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    “I’m drinking four glasses of fluid during a 24-hour period.”

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    “While I’m in the shower, I’ll allow the water to run over my breasts.”

    Quick Answer: 224

    Detailed Answer: 243

  • Damage to the VII cranial nerve results in:

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    Facial pain

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    Absence of ability to smell

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    Absence of eye movement

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    Tinnitus

    Quick Answer: 224

    Detailed Answer: 243

  • A client is receiving Pyridium (phenazopyridine hydrochloride) for a urinary tract infection. The client should be taught that the medication may:

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    Cause diarrhea

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    Change the color of her urine

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    Cause mental confusion

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    Cause changes in taste

    Quick Answer: 224

    Detailed Answer: 244

  • Which of the following tests should be performed before beginning a prescription of Accutane?

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    Check the calcium level.

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    Perform a pregnancy test.

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    Monitor apical pulse.

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    Obtain a creatinine level.

    Quick Answer: 224

    Detailed Answer: 244

  • A client with AIDS is taking Zovirax (acyclovir). Which nursing intervention is most critical during the administration of acyclovir?

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    Limit the client’s activity.

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    Encourage a high-carbohydrate diet.

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    Use an incentive spirometer to improve respiratory function.

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    Encourage fluids.

    Quick Answer: 224

    Detailed Answer: 244

  • A client is admitted for an CAT scan. The nurse should question the client regarding:

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    Pregnancy

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    A titanium hip replacement

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    Allergies to antibiotics

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    Inability to move his feet

    Quick Answer: 224

    Detailed Answer: 244

  • The nurse is caring for the client receiving Amphotericin B. Which of the following indicates that the client has experienced toxicity to this drug?

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    Changes in vision

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    Nausea

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    Urinary frequency

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    Changes in skin color

    Quick Answer: 224

    Detailed Answer: 244

  • The nurse should visit which of the following clients first?

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    The client with diabetes with a blood glucose of 95mg/dL

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    The client with hypertension being maintained on Lisinopril

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    The client with chest pain and a history of angina

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    The client with Raynaud’s disease

    Quick Answer: 224

    Detailed Answer: 244

  • A client with cystic fibrosis is taking pancreatic enzymes. The nurse should administer this medication:

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    Once per day in the morning

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    Three times per day with meals

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    Once per day at bedtime

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    Four times per day

    Quick Answer: 224

    Detailed Answer: 244

  • Cataracts result in opacity of the crystalline lens. Which of the following best explains the functions of the lens?

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    The lens controls stimulation of the retina.

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    The lens orchestrates eye movement.

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    The lens focuses light rays on the retina.

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    The lens magnifies small objects.

    Quick Answer: 224

    Detailed Answer: 244

  • A client who has glaucoma is to have miotic eyedrops instilled in both eyes. The nurse knows that the purpose of the medication is to:

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    Anesthetize the cornea

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    Dilate the pupils

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    Constrict the pupils

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    Paralyze the muscles of accommodation

    Quick Answer: 224

    Detailed Answer: 244

  • A client with a severe corneal ulcer has an order for Gentamicin gtt. q 4 hours and Neomycin 1 gtt q 4 hours. Which of the following schedules should be used when administering the drops?

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    Allow five minutes between the two medications.

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    The medications may be used together.

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    The medications should be separated by a cycloplegic drug.

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    The medications should not be used in the same client.

    Quick Answer: 224

    Detailed Answer: 244

  • The client with color blindness will most likely have problems distinguishing which of the following colors?

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    Orange

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    Violet

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    Red

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    White

    Quick Answer: 224

    Detailed Answer: 244

  • The client with a pacemaker should be taught to:

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    Report ankle edema

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    Check his blood pressure daily

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    Refrain from using a microwave oven

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    Monitor his pulse rate

    Quick Answer: 224

    Detailed Answer: 245

  • The client with enuresis is being taught regarding bladder retraining. The nurse should advise the client to refrain from drinking after:

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    1900

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    1200

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    1000

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    0700

    Quick Answer: 224

    Detailed Answer: 245

  • Which of the following diet instructions should be given to the client with recurring urinary tract infections?

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    Increase intake of meats.

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    Avoid citrus fruits.

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    Perform pericare with hydrogen peroxide.

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    Drink a glass of cranberry juice every day.

    Quick Answer: 224

    Detailed Answer: 245

  • The physician has prescribed NPH insulin for a client with diabetes mellitus. Which statement indicates that the client knows when the peak action of the insulin occurs?

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    “I will make sure I eat breakfast within two hours of taking my insulin.”

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    “I will need to carry candy or some form of sugar with me all the time.”

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    “I will eat a snack around three o’clock each afternoon.”

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    “I can save my dessert from supper for a bedtime snack.”

    Quick Answer: 224

    Detailed Answer: 245

  • A client with pneumacystis carinii pneumonia is receiving Methotrexate. The rationale for administering leucovorin calcium to a client receiving Methotrexate is to:

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    Treat anemia

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    Create a synergistic effect

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    Increase the number of white blood cells

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    Reverse drug toxicity

    Quick Answer: 224

    Detailed Answer: 245

  • A client tells the nurse that she is allergic to eggs, dogs, rabbits, and chicken feathers. Which order should the nurse question?

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    TB skin test

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    Rubella vaccine

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    ELISA test

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    Chest x-ray

    Quick Answer: 224

    Detailed Answer: 245

  • The physician has prescribed ranitidine (Zantac) for a client with erosive gastritis. The nurse should administer the medication:

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    30 minutes before meals

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    With each meal

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    In a single dose at bedtime

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    60 minutes after meals

    Quick Answer: 224

    Detailed Answer: 245

  • A temporary colostomy is performed on the client with colon cancer. The nurse is aware that the proximal end of a double barrel colostomy:

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    Is the opening on the client’s left side

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    Is the opening on the distal end on the client’s left side

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    Is the opening on the client’s right side

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    Is the opening on the distal right side

    Quick Answer: 224

    Detailed Answer: 245

  • While assessing the postpartal client, the nurse notes that the fundus is displaced to the right. Based on this finding, the nurse should:

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    Ask the client to void.

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    Assess the blood pressure for hypotension.

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    Administer oxytocin.

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    Check for vaginal bleeding.

    Quick Answer: 224

    Detailed Answer: 245

  • The physician has ordered an MRI for a client with an orthopedic ailment. An MRI should not be done if the client has:

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    The need for oxygen therapy

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    A history of claustrophobia

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    A permanent pacemaker

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    Sensory deafness

    Quick Answer: 224

    Detailed Answer: 246

  • A six-month-old client is placed on strict bed rest following a hernia repair. Which toy is best suited to the client?

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    Colorful crib mobile

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    Hand-held electronic games

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    Cars in a plastic container

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    30-piece jigsaw puzzle

    Quick Answer: 224

    Detailed Answer: 246

  • The nurse is preparing to discharge a client with a long history of polio. The nurse should tell the client that:

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    Taking a hot bath will decrease stiffness and spasticity.

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    A schedule of strenuous exercise will improve muscle strength.

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    Rest periods should be scheduled throughout the day.

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    Visual disturbances can be corrected with prescription glasses.

    Quick Answer: 224

    Detailed Answer: 246

  • A client on the postpartum unit has a proctoepisiotomy. The nurse should anticipate administering which medication?

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    Dulcolax suppository

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    Docusate sodium (Colace)

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    Methyergonovine maleate (Methergine)

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    Bromocriptine sulfate (Parlodel)

    Quick Answer: 224

    Detailed Answer: 246

  • A client with pancreatic cancer has an infusion of TPN (Total Parenteral Nutrition). The doctor has ordered for sliding-scale insulin. The most likely explanation for this order is:

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    Total Parenteral Nutrition leads to negative nitrogen balance and elevated glucose levels.

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    Total Parenteral Nutrition cannot be managed with oral hypoglycemics.

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    Total Parenteral Nutrition is a high-glucose solution that often elevates the blood glucose levels.

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    Total Parenteral Nutrition leads to further pancreatic disease.

    Quick Answer: 224

    Detailed Answer: 246

  • An adolescent primigravida who is 10 weeks pregnant attends the antepartal clinic for a first check-up. To develop a teaching plan, the nurse should initially assess:

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    The client’s knowledge of the signs of preterm labor

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    The client’s feelings about the pregnancy

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    Whether the client was using a method of birth control

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    The client’s thought about future children

    Quick Answer: 224

    Detailed Answer: 246

  • An obstetric client is admitted with dehydration. Which IV fluid would be most appropriate for the client?

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    .45 normal saline

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    Dextrose 1% in water

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    Lactated Ringer’s

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    Dextrose 5% in .45 normal saline

    Quick Answer: 224

    Detailed Answer: 246

  • The physician has ordered a thyroid scan to confirm the diagnosis of a goiter. Before the procedure, the nurse should:

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    Assess the client for allergies.

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    Bolus the client with IV fluid.

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    Tell the client he will be asleep.

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    Insert a urinary catheter.

    Quick Answer: 224

    Detailed Answer: 246

  • The physician has ordered an injection of RhoGam for a client with blood type A negative. The nurse understands that RhoGam is given to:

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    Provide immunity against Rh isoenzymes

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    Prevent the formation of Rh antibodies

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    Eliminate circulating Rh antibodies

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    Convert the Rh factor from negative to positive

    Quick Answer: 224

    Detailed Answer: 246

  • The nurse is caring for a client admitted to the emergency room after a fall. X-rays reveal that the client has several fractured bones in the foot. Which treatment should the nurse anticipate for the fractured foot?

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    Application of a short inclusive spica cast

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    Stabilization with a plaster-of-Paris cast

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    Surgery with Kirschner wire implantation

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    A gauze dressing only

    Quick Answer: 224

    Detailed Answer: 246

  • A client with bladder cancer is being treated with iridium seed implants. The nurse’s discharge teaching should include telling the client to:

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    Strain his urine

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    Increase his fluid intake

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    Report urinary frequency

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    Avoid prolonged sitting

    Quick Answer: 224

    Detailed Answer: 247

  • Following a heart transplant, a client is started on medication to prevent organ rejection. Which category of medication prevents the formation of antibodies against the new organ?

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    Antivirals

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    Antibiotics

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    Immunosuppressants

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    Analgesics

    Quick Answer: 224

    Detailed Answer: 247

  • The nurse is preparing a client for cataract surgery. The nurse is aware that the procedure will use:

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    Mydriatics to facilitate removal

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    Miotic medications such as Timoptic

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    A laser to smooth and reshape the lens

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    Silicone oil injections into the eyeball

    Quick Answer: 224

    Detailed Answer: 247

  • A client with Alzheimer’s disease is awaiting placement in a skilled nursing facility. Which long-term plans would be most therapeutic for the client?

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    Placing mirrors in several locations in the home

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    Placing a picture of herself in her bedroom

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    Placing simple signs to indicate the location of the bedroom, bathroom, and so on

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    Alternating healthcare workers to prevent boredom

    Quick Answer: 224

    Detailed Answer: 247

  • A client with an abdominal cholecystectomy returns from surgery with a Jackson-Pratt drain. The chief purpose of the Jackson-Pratt drain is to:

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    Prevent the need for dressing changes

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    Reduce edema at the incision

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    Provide for wound drainage

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    Keep the common bile duct open

    Quick Answer: 224

    Detailed Answer: 247

  • The nurse is performing an initial assessment of a newborn Caucasian male delivered at 32 weeks gestation. The nurse can expect to find the presence of:

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    Mongolian spots

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    Scrotal rugae

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    Head lag

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    Polyhydramnios

    Quick Answer: 224

    Detailed Answer: 247

  • The nurse is caring for a client admitted with multiple trauma. Fractures include the pelvis, femur, and ulna. Which finding should be reported to the physician immediately?

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    Hematuria

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    Muscle spasms

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    Dizziness

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    Nausea

    Quick Answer: 224

    Detailed Answer: 247

  • A client is brought to the emergency room by the police. He is combative and yells, “I have to get out of here. They are trying to kill me.” Which assessment is most likely correct in relation to this statement?

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    The client is experiencing an auditory hallucination.

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    The client is having a delusion of grandeur.

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    The client is experiencing paranoid delusions.

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    The client is intoxicated.

    Quick Answer: 224

    Detailed Answer: 247

  • The nurse is preparing to suction the client with a tracheotomy. The nurse notes a previously used bottle of normal saline on the client’s bedside table. There is no label to indicate the date or time of initial use. The nurse should:

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    Lip the bottle and use a pack of sterile 4×4 for the dressing.

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    Obtain a new bottle and label it with the date and time of first use.

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    Ask the ward secretary when the solution was requested.

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    Label the existing bottle with the current date and time.

    Quick Answer: 224

    Detailed Answer: 247

  • An infant’s Apgar score is 9 at five minutes. The nurse is aware that the most likely cause for the deduction of one point is:

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    The baby is hypothermic.

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    The baby is experiencing bradycardia.

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    The baby’s hands and feet are blue.

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    The baby is lethargic.

    Quick Answer: 224

    Detailed Answer: 247

  • The primary reason for rapid continuous rewarming of the area affected by frostbite is to:

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    Lessen the amount of cellular damage

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    Prevent the formation of blisters

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    Promote movement

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    Prevent pain and discomfort

    Quick Answer: 224

    Detailed Answer: 248

  • A client recently started on hemodialysis wants to know how the dialysis will take the place of his kidneys. The nurse’s response is based on the knowledge that hemodialysis works by:

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    Passing water through a dialyzing membrane

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    Eliminating plasma proteins from the blood

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    Lowering the pH by removing nonvolatile acids

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    Filtering waste through a dialyzing membrane

    Quick Answer: 224

    Detailed Answer: 248

  • During a home visit, a client with AIDS tells the nurse that he has been exposed to measles. Which action by the nurse is most appropriate?

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    Administer an antibiotic.

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    Contact the physician for an order for immune globulin.

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    Administer an antiviral.

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    Tell the client that he should remain in isolation for two weeks.

    Quick Answer: 224

    Detailed Answer: 248

  • A client hospitalized with MRSA is placed on contact precautions. Which statement is true regarding precautions for infections spread by contact?

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    The client should be placed in a room with negative pressure.

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    Infection requires close contact; therefore, the door may remain open.

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    Transmission is highly likely, so the client should wear a mask at all times.

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    Infection requires skin-to-skin contact and is prevented by hand washing, gloves, and a gown.

    Quick Answer: 224

    Detailed Answer: 248

  • A client who is admitted with an above-the-knee amputation tells the nurse that his foot hurts and itches. Which response by the nurse indicates understanding of phantom limb pain?

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    “The pain will go away in a few days.”

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    “The pain is due to peripheral nervous system interruptions. I will get you some pain medication.”

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    “The pain is psychological because your foot is no longer there.”

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    “The pain and itching are due to the infection you had before the surgery.”

    Quick Answer: 224

    Detailed Answer: 248

    Quick Answer: 224

    Detailed Answer: 248

  • A client with cancer of the pancreas has undergone a Whipple procedure. The nurse is aware that during the Whipple procedure, the doctor will remove the:

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    Head of the pancreas

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    Proximal third section of the small intestines

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    Stomach and duodenum

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    Esophagus and jejunum

    Quick Answer: 224

    Detailed Answer: 248

  • The physician has ordered a minimal-bacteria diet for a client with neutropenia. The client should be taught to avoid eating:

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    Fruits

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    Salt

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    Pepper

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    Ketchup

    Quick Answer: 224

    Detailed Answer: 248

  • A client is discharged home with a prescription for Coumadin (sodium warfarin). The client should be instructed to:

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    Have a Protime done monthly.

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    Eat more fruits and vegetables.

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    Drink more liquids.

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    Avoid crowds.

    Quick Answer: 224

    Detailed Answer: 248

  • The nurse is assisting the physician with removal of a central venous catheter. To facilitate removal, the nurse should instruct the client to:

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    Perform the Valsalva maneuver as the catheter is advanced

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    Turn his head to the left side and hyperextend the neck

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    Take slow, deep breaths as the catheter is removed

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    Turn his head to the right while maintaining a sniffing position

    Quick Answer: 224

    Detailed Answer: 248

  • A client has an order for streptokinase. Before administering the medication, the nurse should assess the client for:

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    Allergies to pineapples and bananas

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    A history of streptococcal infections

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    Prior therapy with phenytoin

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    A history of alcohol abuse

    Quick Answer: 224

    Detailed Answer: 249

  • The nurse is providing discharge teaching for the client with leukemia. The client should be told to avoid:

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    Using oil- or cream-based soaps

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    Flossing between the teeth

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    The intake of salt

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    Using an electric razor

    Quick Answer: 224

    Detailed Answer: 249

  • The nurse is changing the ties of the client with a tracheotomy. The safest method of changing the tracheotomy ties is to:

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    Apply the new tie before removing the old one.

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    Have a helper present.

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    Hold the tracheotomy with the nondominant hand while removing the old tie.

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    Ask the doctor to suture the tracheostomy in place.

    Quick Answer: 224

    Detailed Answer: 249

  • The nurse is monitoring a client following a lung resection. The hourly output from the chest tube was 300mL. The nurse should give priority to:

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    Turning the client to the left side

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    Milking the tube to ensure patency

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    Slowing the intravenous infusion

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    Notifying the physician

    Quick Answer: 224

    Detailed Answer: 249

  • The infant is admitted to the unit with tetralogy of Fallot. The nurse would anticipate an order for which medication?

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    Digoxin

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    Epinephrine

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    Aminophyline

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    Atropine

    Quick Answer: 224

    Detailed Answer: 249

  • The nurse is educating the lady’s club in self-breast exam. The nurse is aware that most malignant breast masses occur in the Tail of Spence. On the diagram, place an X on the Tail of Spence.

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    Quick Answer: 224

    Detailed Answer: 249

  • The toddler is admitted with a cardiac anomaly. The nurse is aware that the infant with a ventricular septal defect will:

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    Tire easily

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    Grow normally

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    Need more calories

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    Be more susceptible to viral infections

    Quick Answer: 224

    Detailed Answer: 249

  • The nurse is monitoring a client with a history of stillborn infants. The nurse is aware that a nonstress test can be ordered for this client to:

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    Determine lung maturity

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    Measure the fetal activity

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    Show the effect of contractions on fetal heart rate

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    Measure the well-being of the fetus

    Quick Answer: 224

    Detailed Answer: 250

  • The nurse is evaluating the client who was admitted eight hours ago for induction of labor. The following graph is noted on the monitor. Which action should be taken first by the nurse?

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    Instruct the client to push.

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    Perform a vaginal exam.

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    Turn off the Pitocin infusion.

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    Place the client in a semi-Fowler’s position.

    Quick Answer: 224

    Detailed Answer: 250

  • The nurse notes the following on the ECG monitor. The nurse would evaluate the cardiac arrhythmia as:

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    Atrial flutter

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    A sinus rhythm

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    Ventricular tachycardia

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    Atrial fibrillation

    Quick Answer: 224

    Detailed Answer: 250

  • A client with clotting disorder has an order to continue Lovenox (enoxaparin) injections after discharge. The nurse should teach the client that Lovenox injections should:

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    Be injected into the deltoid muscle

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    Be injected into the abdomen

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    Aspirate after the injection

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    Clear the air from the syringe before injections

    Quick Answer: 224

    Detailed Answer: 250

  • The nurse has a preop order to administer Valium (diazepam) 10mg and Phenergan (promethazine) 25mg. The correct method of administering these medications is to:

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    Administer the medications together in one syringe

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    Administer the medication separately

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    Administer the Valium, wait five minutes, and then inject the Phenergan

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    Question the order because they cannot be given at the same time

    Quick Answer: 224

    Detailed Answer: 250

  • A client with frequent urinary tract infections asks the nurse how she can prevent the reoccurrence. The nurse should teach the client to:

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    Douche after intercourse

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    Void every three hours

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    Obtain a urinalysis monthly

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    Wipe from back to front after voiding

    Quick Answer: 224

    Detailed Answer: 250

  • Which task should be assigned to the nursing assistant?

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    Placing the client in seclusion

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    Emptying the Foley catheter of the preeclamptic client

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    Feeding the client with dementia

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    Ambulating the client with a fractured hip

    Quick Answer: 224

    Detailed Answer: 250

  • The client has recently returned from having a thyroidectomy. The nurse should keep which of the following at the bedside?

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    A tracheotomy set

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    A padded tongue blade

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    An endotracheal tube

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    An airway

    Quick Answer: 224

    Detailed Answer: 250

  • The physician has ordered a histoplasmosis test for the elderly client. The nurse is aware that histoplasmosis is transmitted to humans by:

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    A.

    Cats

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    B.

    Dogs

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    C.

    Turtles

    Which assessment findings would the nurse expect in a 3-year-old child with tetralogy of Fallot

    D.

    Birds

    Quick Answer: 224

    Detailed Answer: 250

    • What symptoms would the nurse expect to see in a child with tetralogy of Fallot?

    Signs and symptoms may include:.
    A bluish coloration of the skin caused by low blood oxygen levels (cyanosis).
    Shortness of breath and rapid breathing, especially during feeding or exercise..
    Poor weight gain..
    Tiring easily during play or exercise..
    Irritability..
    Prolonged crying..
    Heart murmur..
    Fainting..

    What are the 4 defects found in tetralogy of Fallot?

    Tetralogy of Fallot is a heart defect made up of four different heart problems: ventricular septal defect, overriding aorta, pulmonary stenosis and right ventricular hypertrophy.

    What is tetralogy of Fallot in infants?

    Tetralogy of Fallot (pronounced te-tral-uh-jee of Fal-oh) is a birth defect that affects normal blood flow through the heart. It happens when a baby's heart does not form correctly as the baby grows and develops in the mother's womb during pregnancy.

    Why does a child with tetralogy of Fallot squat?

    Squatting is a compensatory mechanism, of diagnostic significance, and highly typical of infants with tetralogy of Fallot. Squatting increases peripheral vascular resistance (PVR) and thus decreases the magnitude of the right-to-left shunt across the ventricular septal defect (VSD).

    assessment findings nurse expect 3-year-old child tetralogy fallot

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