The nurse is caring for a toddler with a large, unrepaired ventricular septal defect and heart failure.
What assessment finding should the nurse expect?
Blood pressure variance across extremities.
Hypotension.
Tachycardia.
Pulse oximetry reading within defined limits.
Pulse oximetry reading within defined limits.
The Correct Answer is C
Choice A rationale
Blood pressure variance across extremities is not typically associated with unrepaired ventricular septal defect and heart failure in a toddler.
Choice B rationale
Hypotension is not a typical finding in toddlers with unrepaired ventricular septal defect and heart failure.
Choice C rationale
Tachycardia, or a fast heart rate, is a common symptom in toddlers with unrepaired ventricular septal defect and heart failure. This is because the heart has to work harder to pump blood through the body.
Choice D rationale
While a pulse oximetry reading within defined limits is ideal, it is not a typical finding in toddlers with unrepaired ventricular septal defect and heart failure.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Seizure activity typically presents with symptoms such as convulsions, loss of consciousness, or abnormal behavior, which are not described in the scenario.
Choice B rationale
Arrhythmia, or an abnormal heart rhythm, could potentially cause a sudden drop in oxygen saturation and cyanosis. It could also lead to a rapid response team being called.
Choice C rationale
Increased oxygen demand could potentially lead to low oxygen saturation. However, it would not typically cause cyanosis or require the rapid response team to be called unless it was associated with another condition such as heart or lung disease.
Choice D rationale
Acidosis, or a high level of acid in the body, could potentially cause low oxygen saturation. However, it would not typically cause cyanosis or require the rapid response team to be called unless it was severe or associated with another condition.
Correct Answer is A
Explanation
Choice A rationale
The child’s symptoms of agitation, fever, and back pain, along with a history of asthma and recurrent urinary tract infections (UTIs), suggest that she may be experiencing another UTI1.
UTIs can cause fever and back pain, and the fever can lead to agitation in young children. Administering the prescribed antipyretic would help to reduce the child’s fever and alleviate some of her discomfort.
Choice B rationale
Obstructive uropathy is a condition where the flow of urine is blocked, which can cause pain and kidney damage. While this condition could potentially cause back pain, the child’s other symptoms such as fever and agitation are more indicative of an infection like a UTI1.
Choice C rationale
Albumin is a protein made by the liver that helps keep fluid in the bloodstream so it doesn’t leak into other tissues. It is not a condition but a substance in the body, and therefore would not be the correct answer to the question.
Choice D rationale
V320 is not a known medical condition or term, and therefore would not be the correct answer to the question.
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