The nurse is caring for a child diagnosed with ventricular septal defect (VSD) who is scheduled for a surgical repair tomorrow morning. When the nurse auscultates the child's lungs sounds, the nurse notes diffuse crackles and rales throughout the lung fields. The nurse interprets this assessment as which of the following?
Foreign body aspiration
Systemic congestion
Pneumonia
Pulmonary congestion
The Correct Answer is D
A. Foreign body aspiration is characterized by sudden onset of coughing, choking, and wheezing, not crackles and rales.
B. Systemic congestion refers to peripheral edema and does not usually present with crackles in the lungs.
C. Pneumonia would present with localized crackles or rales over specific lung areas and often includes fever and cough, which are not mentioned here.
D. Pulmonary congestion is common in children with VSD, particularly when the left side of the heart cannot effectively pump blood, leading to fluid accumulation in the lungs. Crackles and rales indicate this type of fluid buildup.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Kawasaki disease typically presents with fever, rash, and conjunctivitis, not a machine-like murmur or the other cardiovascular findings.
B. Tricuspid Atresia involves a defect in the tricuspid valve and presents with cyanosis and poor circulation, but not a machine-like murmur.
C. Tetralogy of Fallot involves a murmur due to pulmonary stenosis and VSD but would not produce a "machine-like" murmur, which is characteristic of PDA.
D. Patent Ductus Arteriosus (PDA) results in a continuous "machine-like" murmur due to abnormal blood flow between the aorta and pulmonary artery, along with findings of pulmonary congestion and right ventricular hypertrophy.
Correct Answer is B
Explanation
A. Croup is a viral infection that typically presents with a barking cough and stridor, rather than difficulty swallowing and excessive drooling.
B. Epiglottitis is a life-threatening condition characterized by sudden onset of fever, drooling, difficulty swallowing, and difficulty speaking (dysphonia). It is a medical emergency and often caused by Haemophilus influenzae type B.
C. Bronchiolitis is usually caused by respiratory syncytial virus (RSV) and presents with wheezing, cough, and respiratory distress but not typically with drooling or difficulty swallowing.
D. Laryngotracheobronchitis (another name for croup) also presents with a barking cough and stridor but does not cause difficulty swallowing or drooling.
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