A nurse is caring for a child who is postoperative following surgical correction of Tetralogy of Fallot. Which of the following findings should the nurse identify as an indication of heart failure?
Weight loss
Decreased respirations
Exercise intolerance
Bradycardia
The Correct Answer is C
Choice A reason: Weight loss is not typically an indication of heart failure. In fact, patients with heart failure may experience weight gain due to fluid retention.
Choice B reason: Decreased respirations are not a common sign of heart failure. Instead, heart failure can cause increased respiratory rate and effort due to fluid accumulation in the lungs.
Choice C reason: Exercise intolerance, or difficulty in engaging in physical activity, is a classic symptom of heart failure. It occurs due to the heart's inability to pump enough blood to meet the body's demands during exercise.
Choice D reason: Bradycardia, or a slower than normal heart rate, is not a direct indication of heart failure. While it can be associated with certain cardiac conditions, it is not a specific sign of heart failure.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Avoiding raw fruits and vegetables is crucial for a child with neutropenia because these foods can harbor bacteria that may cause infection in a child with a weakened immune system. It is important to minimize the risk of infection by providing a diet that includes cooked or thoroughly washed fruits and vegetables.
Choice B reason: Administering vaccines prior to discharge may not be appropriate for a child with neutropenia, as live vaccines are contraindicated due to the risk of infection. Vaccination should be deferred until the child's immune system has recovered.
Choice C reason: Obtaining the child's rectal temperature once daily is not recommended for a child with neutropenia due to the risk of introducing bacteria into the body, which can lead to infection.
Choice D reason: Bathing the child every other day does not directly relate to the care of neutropenia. While personal hygiene is important, the frequency of bathing should be based on the child's needs and condition.
Correct Answer is A
Explanation
Choice A reason: A blood pressure reading of 150/90 mmHg is significantly high for a 7-year-old child and indicates hypertension, which can be a serious complication of acute glomerulonephritis. It is a priority to report this finding to the provider as it may require immediate intervention.
Choice B reason: A BUN level of 20 mg/dL is within the normal range for children and is not typically a cause for immediate concern. However, it should be monitored along with other kidney function tests.
Choice C reason: Urine protein of 12 mg/dL is a common finding in acute glomerulonephritis due to increased permeability of the glomerular membrane. It is important but not as urgent as the blood pressure finding.
Choice D reason: 2+ pedal edema is a sign of fluid retention, which is expected in acute glomerulonephritis. While it should be addressed, it is not as immediately concerning as severe hypertension.
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