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?
Upper extremity hypotension.
Frequent nosebleeds.
Weak femoral pulses.
Increased intracranial pressure.
The Correct Answer is C
Choice A rationale:
Upper extremity hypotension is not a common finding in coarctation of the aorta. Coarctation of the aorta typically results in narrowing of the aorta, leading to decreased blood flow to the lower part of the body. This can cause weak or absent femoral pulses and lower extremity hypotension, not upper extremity hypotension.
Choice B rationale:
Frequent nosebleeds are not directly associated with coarctation of the aorta. The symptoms of coarctation of the aorta are primarily related to decreased blood flow to the lower extremities, leading to symptoms such as weak femoral pulses, lower extremity hypotension, and leg cramping or pain.
Choice D rationale:
Increased intracranial pressure is not a typical finding in coarctation of the aorta. Coarctation of the aorta affects blood flow to the lower part of the body and does not directly impact intracranial pressure.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The correct answer is choice D: Insert an IV saline lock.
Choice D rationale: Inserting an IV saline lock is an appropriate nursing intervention for a client with a tonic-clonic seizure. This allows for quick access to administer intravenous medications, such as anticonvulsants, in case the client experiences another seizure.
Choice A rationale: Providing a tracheostomy tray at the bedside is not necessary for seizure precautions. While maintaining a patent airway is essential during a seizure, it can typically be managed with proper positioning and suctioning if necessary.
Choice B rationale: Placing the client in a supine position is not recommended for seizure precautions. Instead, the client should be placed in a semi-prone or lateral position to promote drainage of secretions and prevent aspiration.
Choice C rationale: Placing a plastic tongue depressor at the client's bedside is not an appropriate intervention. Attempting to insert an object into the client's mouth during a seizure can cause injury and is not recommended.
In summary, the nurse should include inserting an IV saline lock as part of the plan of care for a client who has experienced a tonic-clonic seizure. This will allow for rapid administration of medications, if necessary, while prioritizing client safety and adhering to seizure precautions.
Correct Answer is A
Explanation
The correct answer is A. Interlace the fingers while rubbing hands together. This is one of the steps of performing a surgical hand scrub, which is an antiseptic surgical scrub or antiseptic hand rub that is performed prior to donning surgical attire. Interlacing the fingers helps to remove microorganisms from the spaces between the fingers and under the nails.
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