A nurse is assessing an infant who has congestive heart failure. Which of the following findings should the nurse expect?
Increased urine output
Bradycardia
Increased blood pressure
Tachypnea
The Correct Answer is D
A. Increased urine output. Infants with congestive heart failure (CHF) often have decreased urine output due to reduced kidney perfusion caused by poor cardiac function.
B. Bradycardia. CHF is more likely to cause tachycardia as the heart compensates for poor circulation.
C. Increased blood pressure. CHF in infants typically leads to hypotension or normal blood pressure rather than an increase.
D. Tachypnea. Increased respiratory rate (tachypnea) is a common sign of CHF in infants because of fluid overload and pulmonary congestion, which make breathing difficult.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. "Use barrier ointments around the site." Barrier ointments (such as zinc oxide or petroleum-based products) help prevent skin irritation and breakdown caused by leakage of gastric contents.
B. "Cleanse the tube site with hydrogen peroxide." Hydrogen peroxide can be too harsh and may delay healing or cause irritation to the skin. Mild soap and water or saline are recommended for cleaning.
C. "Maintain tension between the tubing and the site." The tube should be secured but not under tension, as excessive pulling can cause discomfort, skin breakdown, or accidental dislodgement.
D. "Place a transparent occlusive dressing over the site." A gauze dressing may be used if there is drainage, but a transparent occlusive dressing can trap moisture, increasing the risk of infection.
Correct Answer is C
Explanation
A. Lymphadenopathy. While some viral infections cause lymph node swelling, lymphadenopathy is not a hallmark sign of rubeola (measles).
B. Steatorrhea. Steatorrhea (fatty stools) is associated with conditions like cystic fibrosis and celiac disease, not rubeola.
C. Koplik spots. Koplik spots are small, white lesions with a red base found on the buccal mucosa, and they are a classic early sign of measles (rubeola).
D. Paroxysmal coughing. Paroxysmal coughing is characteristic of pertussis (whooping cough), not rubeola.
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