A nurse is collecting data from an infant who has a large patent ductus arteriosus. Which of the following is clinical manifestations should the nurse expect?
Cyanosis with crying
Weak pulses
Chronic hypoxemia
Machine-like murmur
The Correct Answer is D
A. Cyanosis with crying: Cyanosis is less common in isolated PDA and more indicative of other congenital heart defects. PDA usually results in increased pulmonary blood flow and may not directly cause cyanosis, especially in less severe cases.
B. Weak pulses: PDA typically causes increased pulmonary blood flow and can result in bounding pulses rather than weak ones. Weak pulses are more indicative of reduced cardiac output, which is not characteristic of PDA.
C. Chronic hypoxemia: Chronic hypoxemia is less associated with PDA and more common in cyanotic heart defects where oxygenated and deoxygenated blood mix. PDA primarily affects the volume of blood flow to the lungs and may not lead to hypoxemia unless complicated by other conditions.
D. Machine-like murmur: A characteristic feature of PDA is a continuous, machine-like murmur caused by turbulent blood flow between the aorta and the pulmonary artery. This murmur is a hallmark sign of PDA and is typically heard during auscultation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Assist with administering a blood transfusion. Blood transfusions are often necessary in sickle cell crisis to manage severe anemia and improve oxygen delivery to tissues. This action helps alleviate the symptoms of the crisis and prevent complications.
B. Withhold opioids to avoid dependence. Opioids are essential for managing the severe pain associated with sickle cell crises. Concerns about dependence should not prevent adequate pain management in an acute setting.
C. Encourage exercise. During a sickle cell crisis, rest is crucial to reduce oxygen demand and prevent further sickling of red blood cells. Exercise is contraindicated during a crisis.
D. Initiate a 2 L/day fluid restriction. Adequate hydration is critical in managing sickle cell crisis, as it helps prevent further sickling of cells. Fluid restriction is inappropriate and could worsen the condition.
Correct Answer is B
Explanation
A. Capillary refill less than 2 seconds: A capillary refill time of less than 2 seconds indicates good peripheral circulation, which is normal and not a cause for concern in this context. It is not the priority.
B. Tingling in the right foot Rationale: Tingling (paraesthesia) can be a sign of nerve damage or compromised circulation, which may indicate complications such as compartment syndrome. This is a priority finding because it can lead to severe consequences if not addressed promptly.
C. 2+ right pedal pulse Rationale: A 2+ pedal pulse indicates a normal pulse strength, which suggests that there is adequate blood flow to the extremity. It is not a priority compared to the potential for neurological or circulatory compromise.
D. Respiratory rate 24/min Rationale: A respiratory rate of 24/min is within the normal range for a school-age child (18-30 breaths per minute). While it is important to monitor vital signs, it is not a priority concern related to the fracture.
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