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 ["B","C","D","E","F"]
Explanation
Answer is B, C, D, E, F. These are the findings that suggest possible elder abuse or neglect.
- B: Client’s report of lack of food in home. This may indicate neglect by the adult child who is supposed to provide adequate nutrition for the client.
- C: Client’s report of lack of access to bank accounts. This may indicate financial abuse by the adult child who is controlling the client’s money without his permission.
- D: Client’s avoidance of eye contact. This may indicate emotional abuse by the adult child who is intimidating or threatening the client.
- E: Client’s report of weight loss. This may indicate neglect by the adult child who is not meeting the client’s basic needs or physical abuse by the adult child who is causing bodily harm to the client.
- F: Numerous bruises in various stages of healing. This may indicate physical abuse by the adult child who is hitting or injuring the client.
A: ECG results. This is not a finding that suggests elder abuse or neglect. It is a diagnostic test that measures the electrical activity of the heart and can help detect cardiac problems. It does not provide information about the client’s social or emotional well-being.
Normal ranges for vital signs:.
- Temperature: 36.1°C to 37.2°C (97°F to 99°F).
- Heart rate: 60 to 100 beats per minute.
- Blood pressure: less than 120/80 mm Hg.
- Respiratory rate: 12 to 20 breaths per minute.
- SpO2: 95% to 100% on room air. Table for BMI categories:
|
BMI |
Weight Status |
|
Below 18.5 |
Underweight |
|
18.5 to 24.9 |
Normal |
|
25.0 to 29.9 |
Overweight |
|
30.0 and above |
Obese |
The client’s BMI is 18.3, which indicates he is underweight and may be malnourished or have a medical condition that causes weight loss.
Correct Answer is D
Explanation
Choice A reason
Setting the IV infusion pump to administer the blood over 6 hours is not the recommended rate for administering packed RBCs. Blood transfusions are typically given more rapidly, usually within 2 to 4 hours. The specific rate may vary depending on the client's condition and the provider's order.
Choice B reason
Administering the blood via a 21-gauge IV needle is not typically related to the administration of the packed RBCs. The appropriate gauge of the IV needle for blood transfusions depends on the client's condition and the type of transfusion. Larger-gauge needles are often used for blood transfusions to allow for a faster flow rate and prevent haemolysis of the blood cells.
Choice C reason
Checking the client's vital signs from the previous shift prior to the initiation of the transfusion is not sufficient for ensuring the client's safety during the blood transfusion. The nurse should assess the client's current vital signs, including temperature, heart rate, blood pressure, and respiratory rate, before initiating the transfusion. Monitoring vital signs is essential during the transfusion to detect any adverse reactions or changes in the client's condition.
Choice D reason
Rush the blood administration tubing with 0.9% sodium chloride prior to the transfusion is the correct answer. When preparing to administer a blood transfusion to an adult client with chronic anaemia, the nurse should rush the blood administration tubing with 0.9% sodium chloride (normal saline) prior to the transfusion. This process is called priming the tubing.
Priming the tubing helps remove any residual air from the tubing and ensures that the blood transfusion is administered smoothly without introducing air into the client's bloodstream. Air embolisms can be a serious complication, and priming the tubing with normal saline helps prevent this risk.
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