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 D
Explanation
The correct answer is d. Evaluate functioning of the suction device.
Choice D rationale:
- Prompt assessment of the suction device is crucial to determine if it's functioning properly.If the suction is inadequate,it can lead to gastric contents accumulating and potentially causing vomiting.
- Assessing the suction device first allows for timely interventionif it's not working correctly,preventing further complications and discomfort for the client.
Choice A rationale:
- Replacing the NG tube might be necessary if it's dislodged or blocked, but it shouldn't be the immediate action.
- Evaluating the suction device first can help determine if the NG tube itself is the issue or if the problem lies with the suction.
Choice B rationale:
- Providing oral hygiene care is important for comfort and to prevent aspiration, but it's not the priority intervention in this situation.
- Addressing the cause of the vomiting, which could be related to suction malfunction, takes precedence.
Choice C rationale:
- Administering an antiemetic might be helpful to control nausea and vomiting, but it doesn't address the underlying cause.
- Evaluating the suction device first is essential to ensure proper gastric decompression and prevent further vomiting episodes.
Correct Answer is B
Explanation
The correct answer is choice B. Wear clean cotton socks every day.
This is because cotton socks can help keep the feet dry and prevent infections. Wearing clean socks every day can also prevent blisters and injuries from friction.
Choice A is wrong because soaking feet twice daily can make the skin too soft and prone to injury. It can also wash away natural oils that protect the skin.
Choice C is wrong because rounding the edges of toenails when trimming can cause ingrown nails, which can lead to infection and pain. Toenails should be trimmed straight across and filed smooth.
Choice D is wrong because using moisturizing lotion between the toes can create a moist environment that promotes fungal growth. Moisturizing lotion should be applied to the rest of the feet, but not between the toes.
Some other foot care guidelines for people with diabetes are:
- Inspect your feet daily and look for signs of injury, such as scrapes, cuts, blisters, etc.
- Wash your feet every day in warm water with mild soap.
Hot water and harsh soaps can damage your skin. Check the water temperature with your fingers or elbow before putting your feet in.
- Don’t walk barefoot.
Protect your feet from heat and cold. Wear appropriate fitting shoes to avoid injury and blisters.
- See a doctor to remove corns or calluses (don’t do it yourself). Don’t use chemical wart removers, razor blades, corn plasters, or liquid corn or callus removers.
- Don’t sit with your legs crossed or stand in one position for long periods of time.
- See your doctor regularly for foot exams and report any problems or changes in your feet.
References:
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