A newborn child has been diagnosed with tetralogy of Fallot. What symptoms would the nurse expect to observe in this child?

Cyanosis and hypoxia

High-pitched cry and dyspnea

Leg pain and twitching

Epistaxis and anemia

Answer and Explanation

The Correct Answer is A

Choice A rationale
Tetralogy of Fallot is a congenital heart condition that presents with a combination of four defects in the structure of the heart. The most common symptoms in a newborn with this condition include cyanosis (bluish color of the skin due to reduced oxygen in the blood) and hypoxia (low levels of oxygen in the body)34567.
Choice B rationale
While a high-pitched cry can be a sign of distress in a newborn, it is not specifically associated with tetralogy of Fallot. Dyspnea (difficulty breathing) can occur in severe cases, but it is not one of the primary symptoms of this condition.
Choice C rationale
Leg pain and twitching are not typical symptoms of tetralogy of Fallot. These symptoms could be indicative of other conditions, but they are not associated with this specific congenital heart defect.
Choice D rationale
Epistaxis (nosebleeds) and anemia are not typical symptoms of tetralogy of Fallot. While these conditions can occur in children for various reasons, they are not directly related to this specific congenital heart defect.

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Correct Answer is C

Explanation

The correct answer is choice c. Carry out immediate defibrillation.

Choice A rationale:

Initiating cardiopulmonary resuscitation (CPR) is essential for a client who is unresponsive and without a pulse. However, in the presence of ventricular fibrillation, immediate defibrillation is the priority to restore a viable heart rhythm.

Choice B rationale:

Establishing intravenous (IV) access is important for administering medications during resuscitation. However, it is not the immediate priority when defibrillation is indicated.

Choice C rationale:

Immediate defibrillation is the priority action for a client with ventricular fibrillation who is unresponsive and without a pulse. Defibrillation can quickly restore a normal heart rhythm, which is critical in saving the client’s life.

Choice D rationale:

Checking the client’s latest electrolyte levels can provide valuable information for ongoing treatment but is not the immediate priority in an emergency situation where defibrillation is indicated. Immediate action to restore the heart rhythm is more critical.

A. Sinus tachycardia at a rate of 110 beats/min. B. Blood pressure increase from 134/68 to 150/80 mm Hg. C. The patient reports feeling tired. D. Inversion of T waves on the electrocardiogram.

Correct Answer is D

Explanation

Choice A rationale
Sinus tachycardia at a rate of 110 beats/min is a normal response to exercise. During a stress test, the heart rate will naturally increase as the body’s demand for oxygen increases. A heart rate of 110 beats/min is within the expected range during moderate exercise.
Choice B rationale
An increase in blood pressure from 134/68 to 150/80 mm Hg is a normal response to exercise. During a stress test, blood pressure will naturally rise as the heart works harder to pump blood to the muscles. This increase is within the expected range during moderate exercise.
Choice C rationale
Feeling tired during a stress test on a treadmill is a normal response to exercise. Fatigue can occur as the body’s energy stores are used up during physical activity. However, if the patient reports extreme fatigue or other symptoms such as chest pain or shortness of breath, it may indicate a problem.
Choice D rationale
Inversion of T waves on the electrocardiogram during a stress test is a sign of myocardial ischemia, a condition in which the heart muscle is not getting enough oxygen. This could indicate the presence of significant coronary artery disease and is a finding that would necessitate immediate action.

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A newborn child has been diagnosed with tetralogy of Fallot. What symptoms would the nurse expect to observe in this child?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Given the electrocardiogram tracing below for a client who is unresponsive and without a pulse, what should be the nurse’s priority action?

Correct Answer is C

Explanation

During a stress test on a treadmill, which observation by the nurse would necessitate immediate action?

Correct Answer is D

Explanation

An older patient with chronic atrial fibrillation develops sudden severe pain, pulselessness, pallor, and coolness in the right leg, consistent with acute arterial occlusion. After the nurse notifies the healthcare provider, what should the nurse do next?

The nurse is providing care for a patient with the following tracing on the electrocardiogram (ECG) for atrial fibrillation. What prescription should the nurse anticipate from the primary healthcare provider (PHCP)?

After the shift change, which patient in the emergency department should the nurse prioritize for assessment?

While conducting an admission assessment, the nurse observes clubbing of the patient’s fingers. Based on this finding, the nurse should he patient about which disease process?

The nurse is reviewing the laboratory test results for a patient who has recently been diagnosed with hypertension. Which result is most important to communicate to the health care provider?

A nurse is caring for a client who has developed cardiac tamponade. Which of the following symptoms should the nurse expect to observe?

When caring for a client who has developed cardiac tamponade, what assessments should the nurse expect to find?