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
Logo

Nursing Elites

HESI LPN

Medical Surgical HESI

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. A client with a history of hypertension is admitted with a blood pressure of 220/120 mm Hg. What is the priority nursing action?

Correct answer: A

Rationale: Administering antihypertensive medication is the priority nursing action in this situation. The extremely high blood pressure of 220/120 mm Hg puts the client at risk of severe complications such as stroke, heart attack, or kidney damage. Lowering the blood pressure promptly is crucial to prevent these complications. Placing the client in a supine position or obtaining a detailed health history are not immediate actions needed to address the hypertensive crisis. Monitoring urine output, although important, is not the priority when the client's blood pressure is critically high.

3. What is the hallmark sign of intussusception?

Correct answer: B

Rationale: The hallmark sign of intussusception is currant jelly-like stools, which result from the mixture of blood and mucus in the stool due to the sloughing of intestinal mucosa. Mucus-like stools (Choice A) are not typically associated with intussusception. Tarry, black stools (Choice C) are characteristic of gastrointestinal bleeding higher up in the gastrointestinal tract, such as from a peptic ulcer. Green, soft stools (Choice D) are more indicative of rapid transit through the intestines, possibly due to dietary factors or infections such as gastroenteritis.

4. The family of a newly admitted child with cystic fibrosis is educated by the nurse that the treatment will be centered on what therapy?

Correct answer: A

Rationale: The correct answer is A: Chest physiotherapy. In cystic fibrosis, chest physiotherapy and aerosol medications are fundamental components of treatment to help clear mucus from the lungs, reduce the risk of infections, and improve breathing. Mucus-drying agents (Choice B) are not typically used in the treatment of cystic fibrosis. Prevention of diarrhea (Choice C) is not a primary focus in the treatment of cystic fibrosis. Insulin therapy (Choice D) is not relevant to cystic fibrosis, as it is a treatment for diabetes.

5. A client with chronic heart failure is experiencing dyspnea and has an oxygen saturation of 88%. Which position is most appropriate to improve oxygenation?

Correct answer: B

Rationale: The correct answer is B: High Fowler's position. High Fowler's position is the most appropriate for a client with chronic heart failure experiencing dyspnea and low oxygen saturation. This position helps improve lung expansion and oxygenation by maximizing chest expansion and allowing better ventilation. Choice A, supine with legs elevated, may worsen dyspnea by reducing lung expansion. Choice C, prone with pillows under the chest, is not suitable for a client experiencing dyspnea as it may further compromise breathing. Choice D, side-lying with head flat, does not facilitate optimal lung expansion and is not the best choice for improving oxygenation in this scenario.

Similar Questions

The nurse prepares a teaching plan for an adult client with metabolic syndrome. Which findings should the nurse address to help the client reduce the risk for diabetes mellitus and vascular disease? (Select all that apply)
A client with deep vein thrombosis (DVT) is receiving heparin therapy. Which laboratory test should the nurse monitor to evaluate the effectiveness of the heparin?
A client with AIDS has impaired gas exchange from a respiratory infection. Which assessment finding warrants immediate intervention by the nurse?
A young adult male is admitted to the intensive care unit with multiple rib fractures and severe pulmonary contusions after falling 20 feet from a rooftop. The Chest X-ray suggests acute Respiratory distress Syndrome. Which assessment finding warrants immediate intervention by the Nurse?
A male client tells the nurse that he is experiencing burning on urination, and assessment reveals that he had sexual intercourse four days ago with a woman he casually met. Which action should the nurse implement?

Access More Features

HESI LPN Basic
$69.99/ 30 days

  • 5,000 Questions with answers
  • All HESI courses Coverage
  • 30 days access

HESI LPN Premium
$149.99/ 90 days

  • 5,000 Questions with answers
  • All HESI courses Coverage
  • 30 days access

Other Courses