A nurse in a provider's office is collecting baseline preoperative data from a 5-month-old infant who has coarctation of the aorta. Which of the following locations should the nurse palpate to check for the presence of the infant's femoral pulse? (You will find hot spots to select in the artwork below. Select only the hot spot that corresponds to your answer).

Answer and Explanation

The Correct Answer is "{\"xRanges\":[111.828125,122.828125],\"yRanges\":[106.5,117.5]}"

A: Location A is near the infant’s foot, specifically around the ankle. This area is where the posterior tibial or dorsalis pedis pulse would be palpated, not the femoral pulse. These pulses are important for assessing peripheral circulation but are not the primary site for evaluating coarctation of the aorta, which requires checking central pulses like the femoral.

B: Location B is at the upper inner thigh, near the groin, where the femoral artery passes close to the skin surface. This is the correct site for palpating the femoral pulse in an infant. In conditions like coarctation of the aorta, comparing the strength of the brachial and femoral pulses is crucial to detect differences in blood flow between the upper and lower body.

C: Location C is on the upper arm, near the shoulder area, which corresponds to the location for checking the brachial pulse. The brachial pulse is commonly used in infants to assess heart rate, especially during resuscitation efforts. However, it is not the site for assessing femoral pulse strength, which is needed when evaluating for coarctation of the aorta.

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Correct Answer is B

Explanation

A. Temperature of 37.2° C (99.0° F): A temperature of 37.2° C is within the normal range and does not necessarily indicate infection. Mild temperature elevations are common in the immediate postoperative period due to inflammatory responses rather than infection, which typically presents with more significant fever.

B. Elevated WBC count: An elevated white blood cell (WBC) count is a classic and early indicator of infection. It reflects the body's immune response to a bacterial or viral invasion, and postoperative infections often present with leukocytosis, making it a key finding to monitor closely.

C. Pain rating of 4 on a scale of 0 to 10: Moderate pain is expected after surgery and does not, by itself, suggest infection. Postoperative pain should be assessed in context with other symptoms like redness, swelling, or drainage; pain alone, especially if stable, is not definitive for infection.

D. Increased urinary output: Increased urinary output is generally a positive sign of good kidney perfusion and hydration status. A decrease, not an increase, in urinary output would be more concerning postoperatively and could suggest complications, but not necessarily infection.

A. Take vital signs on clients as they are admitted. B. Respond to family members about a client's condition C. Clean and dress client abdominal wounds. D. Determine which clients should be seen first.

Correct Answer is A

Explanation

A. Take vital signs on clients as they are admitted: Taking vital signs is within the scope of practice for assistive personnel (AP) and is an essential task during a mass casualty event. It provides critical baseline information that the licensed staff can use to prioritize care and identify urgent needs.

B. Respond to family members about a client's condition: Communicating about a client's medical condition requires clinical judgment and is the responsibility of licensed nursing staff or healthcare providers. APs are not trained or authorized to give out clinical information to family members.

C. Clean and dress client abdominal wounds: Wound care, especially for open or surgical wounds like those on the abdomen, involves assessment and sterile technique, which must be performed by licensed personnel, not assistive personnel.

D. Determine which clients should be seen first: Determining client priority, also known as triage, requires nursing knowledge, critical thinking, and clinical assessment skills. It is a responsibility that falls to licensed nurses, not assistive personnel.

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Naxlex Comprehensive Predictor Exams

A nurse is collecting data from a client who is 2 days postoperative following abdominal surgery. Which of the following findings is a manifestation that can indicate an infection?

Correct Answer is B

Explanation

A nurse is assisting with the care of a group of clients during a mass casualty event. Which of the following tasks should the nurse assign to an assistive personnel (APIT

Correct Answer is A

Explanation

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