the nurse instructs the mother of a child with a ventricular septal defect that she can expect the child to become cyanotic when the child does what
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1. The nurse instructs the mother of a child with a ventricular septal defect that she can expect the child to become cyanotic when the child does what?

Correct answer: C

Rationale: The correct answer is C: Cries vigorously. When the child cries vigorously, it increases the pressure in the right ventricle, allowing unoxygenated blood to enter the circulating volume, leading to cyanosis. This occurs due to the shunting of blood from the right side of the heart to the left side through the ventricular septal defect. Choices A, B, and D are incorrect because they do not directly impact the pressure in the right ventricle, which is crucial in causing cyanosis in this scenario.

2. In planning care for a postoperative client with hypovolemic shock, which problem is most important to include in the plan of care?

Correct answer: B

Rationale: The correct answer is B: Risk for falls. In a postoperative client with hypovolemic shock, the most crucial problem to address is the risk for falls. Hypovolemic shock can result in dizziness and weakness, making the client prone to falling. Preventing falls is essential to avoid further injury or complications. Choices A, C, and D are not the top priority in this scenario. While infection, impaired skin integrity, and activity intolerance are important concerns, preventing falls takes precedence due to the immediate risk of injury associated with hypovolemic shock.

3. Following surgical repair of the bladder, a female client is being discharged from the hospital to home with an indwelling urinary catheter. Which instruction is most important for the nurse to provide to this client?

Correct answer: C

Rationale: The most crucial instruction for a client with an indwelling urinary catheter post-bladder surgery is to keep the drainage bag positioned lower than the level of the bladder. This positioning prevents backflow of urine into the bladder, reducing the risk of infection. Choice A, avoiding coiling the tubing and keeping it free of kinks, is important to maintain proper flow but not as critical as ensuring the drainage bag is lower than the bladder. Choice B, cleansing the perineal area, is essential for overall hygiene but not directly related to catheter care instructions. Choice D, drinking fluids to irrigate the catheter, is not recommended as it may increase the risk of infection and should be guided by healthcare providers based on specific needs.

4. The nurse is evaluating teaching about drug therapy to treat gout. Which statement by the client demonstrates an understanding of the use of allopurinol to treat Gout?

Correct answer: B

Rationale: Taking allopurinol every day helps to prevent gout flare-ups by reducing uric acid levels.

5. How should the nurse record the observation of a child with Duchenne muscular dystrophy rising from the floor by walking up the thighs with the hands?

Correct answer: C

Rationale: The correct term for a child with Duchenne muscular dystrophy rising from the floor by walking up the thighs with the hands is known as the Gowers sign. This maneuver is characteristic of Duchenne muscular dystrophy due to proximal muscle weakness. Choices A, B, and D are incorrect because they do not specifically describe the action of walking up the thighs with the hands, which is a distinctive feature of the Gowers sign.

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