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Test 3 Saunders NCLEX questions with verified solutions
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Test 3 Saunders NCLEX questions with verified solutions
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Test 3 Saunders NCLEX questions withverified solutions
The nurse is monitoring an infant with congenital heart disease closely for signs of heart failure (HF). The
nurse should assess the infant for which early sign of HF?
1.Pallor
2.Cough
3.Tachycardia
4.Slow and shallow breathing - correct answer ✔✔3 Rationale:
Heart failure (HF) is the inability of the heart to pump a sufficient amount of blood to meet the oxygen
and metabolic needs of the body. The early signs of HF include tachycardia, tachypnea, profuse scalp
sweating, fatigue and irritability, sudden weight gain, and respiratory distress. A cough may occur in HF
as a result of mucosal swelling and irritation, but is not an early sign. Pallor may be noted in an infant
with HF, but is not an early sign.
The nurse reviews the laboratory results for a child with a suspected diagnosis of rheumatic fever,
knowing that which laboratory study would assist in confirming the diagnosis?
1.Immunoglobulin
2.Red blood cell count
3.White blood cell count
4.Anti-streptolysin O titer - correct answer ✔✔4 Rationale:
Rheumatic fever is an inflammatory autoimmune disease that affects the connective tissues of the heart,
joints, skin (subcutaneous tissues), blood vessels, and central nervous system. A diagnosis of rheumatic
fever is confirmed by the presence of two major manifestations or one major and two minor
manifestations from the Jones criteria. In addition, evidence of a recent streptococcal infection is
confirmed by a positive anti-streptolysin O titer, Streptozyme assay, or anti-DNase B assay. Options 1, 2,
and 3 would not help to confirm the diagnosis of rheumatic fever.
On assessment of a child admitted with a diagnosis of acute-stage Kawasaki disease, the nurse expects to
note which clinical manifestation of the acute stage of the disease?
1.Cracked lips
2.Normal appearance
,3.Conjunctival hyperemia
4.Desquamation of the skin - correct answer ✔✔3 Rationale:
Kawasaki disease, also known as mucocutaneous lymph node syndrome, is an acute systemic
inflammatory illness. In the acute stage, the child has a fever, conjunctival hyperemia, red throat, swollen
hands, rash, and enlargement of the cervical lymph nodes. In the subacute stage, cracking lips and
fissures, desquamation of the skin on the tips of the fingers and toes, joint pain, cardiac manifestations,
and thrombocytosis occur. In the convalescent stage, the child appears normal, but signs of inflammation
may be present
The nurse provides home care instructions to the parents of a child with heart failure regarding the
procedure for administration of digoxin (Lanoxin). Which statement made by the parent indicates the
need for further instructions?
1."I will not mix the medication with food."
2."I will take my child's pulse before administering the medication."
3."If more than one dose is missed, I will call the health care provider."
4."If my child vomits after medication administration, I will repeat the dose." - correct answer ✔✔4
Rationale:
Digoxin is a cardiac glycoside. The parents need to be instructed that if the child vomits after digoxin is
administered, they are not to repeat the dose. Options 1, 2, and 3 are accurate instructions regarding the
administration of this medication. In addition, the parents should be instructed that if a dose is missed
and is not identified until 4 hours later, the dose should not be administered
The nurse is closely monitoring the intake and output of an infant with heart failure who is receiving
diuretic therapy. The nurse should use which most appropriate method to assess the urine output?
1.Weighing the diapers
2.Inserting a Foley catheter
3.Comparing intake with output
4.Measuring the amount of water added to formula - correct answer ✔✔1 Rationale:
Heart failure is the inability of the heart to pump a sufficient amount of blood to meet the oxygen and
metabolic needs of the body. The most appropriate method for assessing urine output in an infant
receiving diuretic therapy is to weigh the diapers. Comparing intake with output would not provide an
accurate measure of urine output. Measuring the amount of water added to formula is unrelated to the
amount of output. Although Foley catheter drainage is most accurate in determining output, it is not the
most appropriate method in an infant and places the infant at risk for infection.
,The clinic nurse reviews the record of a child just seen by a health care provider and diagnosed with
suspected aortic stenosis. The nurse expects to note documentation of which clinical manifestation
specifically found in this disorder?
1.Pallor
2.Hyperactivity
3.Exercise intolerance
4.Gastrointestinal disturbances - correct answer ✔✔3 Rationale:
Aortic stenosis is a narrowing or stricture of the aortic valve, causing resistance to blood flow in the left
ventricle, decreased cardiac output, left ventricular hypertrophy, and pulmonary vascular congestion. A
child with aortic stenosis shows signs of exercise intolerance, chest pain, and dizziness when standing for
long periods. Pallor may be noted, but is not specific to this type of disorder alone. Options 2 and 4 are
not related to this disorder.
The nurse has provided home care instructions to the parents of a child who is being discharged after
cardiac surgery. Which statement made by the parents indicates a need for further instructions?
1."A balance of rest and exercise is important."
2."I can apply lotion or powder to the incision if it is itchy."
3."Activities in which my child could fall need to be avoided for 2 to 4 weeks."
4."Large crowds of people need to be avoided for at least 2 weeks after surgery." - correct answer ✔✔2
Rationale:
The mother should be instructed that lotions and powders should not be applied to the incision site after
cardiac surgery. Lotions and powders can irritate the surrounding skin, which could lead to skin
breakdown and subsequent infection of the incision site. Options 1, 3, and 4 are accurate instructions
regarding home care after cardiac surgery.
A child with rheumatic fever will be arriving in the nursing unit for admission. On admission assessment,
the nurse should ask the parents which question to elicit assessment information specific to the
development of rheumatic fever?
1."Has the child complained of back pain?"
, 2."Has the child complained of headaches?"
3."Has the child had any nausea or vomiting?"
4."Did the child have a sore throat or fever within the last 2 months?" - correct answer ✔✔4 Rationale:
Rheumatic fever is an inflammatory autoimmune disease that affects the connective tissues of the heart,
joints, skin (subcutaneous tissues), blood vessels, and central nervous system. Rheumatic fever
characteristically manifests 2 to 6 weeks after an untreated or partially treated group A b-hemolytic
streptococcal infection of the upper respiratory tract. Initially, the nurse determines whether the child
had a sore throat or an unexplained fever within the past 2 months. Options 1, 2, and 3 are unrelated to
rheumatic fever.
A health care provider has prescribed oxygen as needed for an infant with heart failure. In which
situation should the nurse administer the oxygen to the infant?
1.During sleep
2.When changing the infant's diapers
3.When the mother is holding the infant
4.When drawing blood for electrolyte level testing - correct answer ✔✔4 Rationale:
Heart failure (HF) is the inability of the heart to pump a sufficient amount of blood to meet the oxygen
and metabolic needs of the body. Crying exhausts the limited energy supply, increases the workload of
the heart, and increases the oxygen demands. Oxygen administration may be prescribed for stressful
periods, especially during bouts of crying or invasive procedures. Options 1, 2, and 3 are not likely to
produce crying in the infant.
The nurse is caring for an infant with a diagnosis of tetralogy of Fallot. The infant suddenly becomes
cyanotic, and the nurse recognizes that the infant is experiencing a hypercyanotic spell (blue or tet spell).
The nurse immediately places the infant in what position?
1.Prone position
2.Knee-chest position
3.High Fowler's position
4.Reverse Trendelenburg's position - correct answer ✔✔2 Rationale:
Tetralogy of Fallot includes four defects-ventricular septal defect, pulmonary stenosis, overriding aorta,
and right ventricular hypertrophy. If pulmonary vascular resistance is higher than systemic resistance, the
shunt is from right to left; if systemic resistance is higher than pulmonary resistance, the shunt is left to
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