A nurse is collecting data from an infant a large patent ductus arteriosus. Which of the following is clinical manifestations should the nurse expect?
Machine like murmur
Chronic hypoxemia
Cyanosis with crying
Weak pulse
The Correct Answer is A
A. Machine-like murmur.
This option is correct. A characteristic clinical manifestation of a large patent ductus arteriosus is a continuous "machine-like" murmur heard on auscultation. This murmur is typically heard best at the upper left sternal border and may radiate to the back.
B. Chronic hypoxemia.
Chronic hypoxemia is not typically a primary manifestation of a large PDA. While PDA can lead to increased pulmonary blood flow and potentially contribute to pulmonary congestion, chronic hypoxemia may not be a prominent feature unless complications such as heart failure develop.
C. Cyanosis with crying.
Cyanosis with crying is more commonly associated with cyanotic congenital heart defects such as tetralogy of Fallot. While PDA can contribute to cyanosis in certain circumstances, it is not typically a consistent clinical manifestation.
D. Weak pulse.
A weak pulse is not typically associated specifically with a large PDA. Infants with PDA may have bounding pulses due to increased blood flow through the ductus arteriosus.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Drink eight glasses of fluid daily: This is crucial advice for patients with sickle cell anemia, as adequate hydration helps prevent sickling of red blood cells and reduces the risk of vaso-occlusive crises. Therefore, this precaution is appropriate and should be included in discharge teaching.
B. Maintain an updated Haemophilus influenzae type b (Hib) immunization: While vaccination is essential for overall health, maintaining Hib immunization is not directly related to sickle cell anemia or vaso-occlusive crises. However, it's still important for the child's general well-being and should be addressed but may not be the priority in discharge teaching for sickle cell anemia.
C. Avoid playground activities at school: Children with sickle cell anemia are at risk of vaso-occlusive crises triggered by dehydration, fatigue, or extreme physical exertion. While playground activities can be strenuous, completely avoiding them may not be necessary. Instead, the child should be educated on the importance of staying hydrated, taking breaks when needed, and avoiding excessive physical strain.
D. Assume postural drainage positions every 6 hours: Postural drainage is not typically indicated for sickle cell anemia or vaso-occlusive crises unless there are specific respiratory complications. This precaution is not relevant to the management of sickle cell anemia and should not be included in discharge teaching for this condition.
Correct Answer is ["B","D"]
Explanation
A. Cranberry juice
Cranberry juice may be too acidic and could irritate the surgical site. It's best to avoid acidic beverages immediately following a tonsillectomy.
B. Ice-cream
This option is suitable. Ice-cream is cold and soothing, and it can help numb the throat, providing relief from discomfort after a tonsillectomy. However, it's essential to ensure that the ice-cream is not too cold to avoid causing discomfort.
C. Hot tea
Hot tea is not recommended immediately following a tonsillectomy. Hot liquids can irritate the surgical site and may cause discomfort. It's best to avoid hot beverages until the throat has had time to heal.
D. Italian ice
Italian ice is a frozen dessert similar to a slushy, and it can be a suitable option after a tonsillectomy. Like ice-cream, Italian ice is cold and can help numb the throat, providing relief from discomfort.
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