A nurse is caring for an infant who has coarctation of the aorta. Which of the following should the nurse identify as an expected finding?
Frequent nosebleeds
Increased intracranial pressure
Upper extremity hypotension
Weak femoral pulses
The Correct Answer is D
A. Frequent nosebleeds: While hypertension can occur in coarctation of the aorta, frequent nosebleeds are not a typical finding associated with this condition.
B. Increased intracranial pressure: This is not a direct finding of coarctation of the aorta. Increased intracranial pressure may be related to other conditions, but it is not specifically expected in this context.
C. Upper extremity hypotension: In coarctation of the aorta, the upper extremities usually experience higher blood pressure due to the narrowing of the aorta distal to the branches supplying the arms. Therefore, hypotension in the upper extremities is not expected.
D. Weak femoral pulses: This is an expected finding in coarctation of the aorta, as the narrowing of the aorta can lead to decreased blood flow to the lower body, resulting in weak or diminished femoral pulses compared to the upper extremities.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. "Limit your child's potassium intake while she is taking this medication.": This statement is incorrect. In fact, potassium intake should generally be adequate because digoxin can lead to increased potassium loss, and low potassium levels can increase the risk of digoxin toxicity.
B. “Repeat the dose if your child vomits within 1 hour after taking the medication.": This statement is not recommended. The nurse should advise parents to contact their healthcare provider for guidance on whether to administer a repeat dose after vomiting, as it depends on the individual situation and timing.
C. "Have your child drink a small glass of water after swallowing the medication.": This statement is appropriate as it can help ensure that the medication is swallowed properly and aids in its absorption. Adequate hydration is important for all medications.
D. "You can add the medication to a half-cup of your child's favorite juice.": This is not advisable because mixing digoxin with juice can alter the absorption of the medication. It's generally better to administer it alone to ensure proper dosing and effectiveness.
Correct Answer is C
Explanation
A) Leaving a nasogastric tube clamped after administering oral medication: Leaving a nasogastric tube clamped after administering oral medication can lead to complications such as aspiration or improper medication delivery. However, it is not typically classified as malpractice unless it results in significant harm to the patient.
B) Documenting communication with a provider in the progress notes of the client’s medical record: Documenting communication with a provider in the progress notes is a standard and necessary practice in nursing. It ensures that there is a clear record of the care provided and any instructions given by the healthcare provider.
C) Administering potassium via IV bolus: Administering potassium intravenously as a rapid injection (bolus) can be extremely dangerous and potentially lethal. Potassium should be administered slowly to avoid causing cardiac arrest. This action is a clear example of malpractice due to the severe risk it poses to the patient.
D) Placing a yellow bracelet on a client who is at risk for falls: Placing a yellow bracelet on a client who is at risk for falls is a standard safety measure to alert staff to the client’s fall risk. This action is part of good nursing practice and helps prevent potential injuries.
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