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
Upper extremity hypotension
Weak femoral pulses.
Increased intracranial pressure
The Correct Answer is C
This is because coarctation of the aorta is a congenital condition where the aorta is narrow, usually in the area where the ductus arteriosus inserts. This causes a decrease in blood flow to the lower body, resulting in weak or absent pulses in the femoral arteries.
The other choices are incorrect for the following reasons:
- Choice A, frequent nosebleeds, is not a typical sign of coarctation of the aorta.
Nosebleeds can be caused by many factors, such as dry air, allergies, trauma, or bleeding disorders.
- Choice B, upper extremity hypotension, is also not a common finding in coarctation of the aorta. In fact, patients with this condition may have high blood pressure in the upper extremities due to the increased resistance of the narrowed aorta.
- Choice D, increased intracranial pressure, is not directly related to coarctation of the aorta.
Increased intracranial pressure can be caused by various conditions that affect the brain, such as head injury, stroke, infection, or tumor.
Normal ranges for blood pressure and pulse vary depending on age, sex, and health status.
However, some general guidelines are:
- Blood pressure: less than 120/80 mmHg for adults; less than 95/65 mmHg for infants.
- Pulse: 60 to 100 beats per minute for adults; 100 to 160 beats per minute for infants.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
These are signs of severe dehydration in an infant, which can be life-threatening and should be reported to the provider immediately. The infant may need intravenous fluids and electrolytes to restore hydration and prevent complications.
Choice B is wrong because a temperature of 38° C (100.4° F) and pulse rate of 124/min are not abnormal for an infant and do not indicate severe dehydration. These are common findings in an infant who has gastroenteritis, which is an inflammation of the stomach and intestines caused by a virus, bacteria, or parasite.
Choice C is wrong because decreased appetite and irritability are also common findings in an infant who has gastroenteritis, but they do not indicate severe dehydration. The nurse should encourage oral rehydration with fluids such as breast milk, formula, or oral electrolyte solution.
Choice D is wrong because pale skin and a 24-hr fluid deficit of 30 mL are not signs of severe dehydration in an infant.
A fluid deficit of 30 mL is less than 1 oz and is not significant for an infant who weighs about 10 kg (22 lbs). A fluid deficit of more than 10% of body weight would indicate severe dehydration.
Normal ranges for vital signs in infants are as follows:
- Temperature: 36.5° C to 37.5° C (97.7° F to 99.5° F)
- Pulse rate: 100 to 160/min
- Respiratory rate: 30 to 60/min
- Blood pressure: 65/41 to 100/50 mm Hg
Normal ranges for fluid intake and output in infants are as follows:
- Fluid intake: 100 to 150 mL/kg/day
- Fluid output: 1 to 2 mL/kg/hr
Correct Answer is B
Explanation
The correct answer is choice B. The client should keep the medication in the original container.
Dabigatran is a blood thinner that is used to prevent strokes or blood clots in people with atrial fibrillation, a type of irregular heartbeat. Dabigatran is sensitive to moisture and can lose its potency if exposed to humidity or heat. Therefore, it is important to store it in the original bottle or blister package that has a desiccant (drying agent) in the cap or cover. The client should also close the cap tightly after each use and keep the bottle away from excessive moisture, heat, and cold.
Choice A is wrong because storing the medication in the refrigerator can expose it to moisture and cause it to break down. Choice C is wrong because crushing the medication and mixing it with applesauce can alter its absorption and effectiveness. Choice D is wrong because the medication can be used up to 60 days after opening the bottle as long as it is stored properly. The normal dose of dabigatran for stroke prevention in atrial fibrillation is 150 mg twice a day, unless the client has kidney problems or other factors that require a lower dose.
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