A nurse is caring for an infant who has coarctation of the aorta. Which of the following should the nurse identify as an expected finding?

Frequent nosebleeds

Increased intracranial pressure

Upper extremity hypotension

Weak femoral pulses

Answer and Explanation

The Correct Answer is D

A. Frequent nosebleeds: While hypertension can occur in coarctation of the aorta, frequent nosebleeds are not a typical finding associated with this condition.

B. Increased intracranial pressure: This is not a direct finding of coarctation of the aorta. Increased intracranial pressure may be related to other conditions, but it is not specifically expected in this context.

C. Upper extremity hypotension: In coarctation of the aorta, the upper extremities usually experience higher blood pressure due to the narrowing of the aorta distal to the branches supplying the arms. Therefore, hypotension in the upper extremities is not expected.

D. Weak femoral pulses: This is an expected finding in coarctation of the aorta, as the narrowing of the aorta can lead to decreased blood flow to the lower body, resulting in weak or diminished femoral pulses compared to the upper extremities.

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Correct Answer is C

Explanation

A. Place the sterile dressing within 1.25 cm (0.5 in) of the edge of the sterile field: This action is not appropriate, as sterile items should be placed at least 2.5 cm (1 in) away from the edge of the sterile field to maintain sterility and prevent contamination.

B. Open the outermost flap of the sterile kit toward the body: The correct practice is to open the outermost flap away from the body. This technique helps prevent any contaminants from the nurse's clothing or body from falling into the sterile field.

C. Place the cap from the solution sterile side up on a clean surface: This is the correct action. By placing the cap sterile side up, the nurse minimizes the risk of contamination to the sterile solution and maintains the integrity of the sterile field.

D. Set up the sterile field 5 cm (2 in) below waist level: Setting up a sterile field below waist level increases the risk of contamination, as it may come into contact with non-sterile surfaces. The sterile field should be set up at waist level or higher to maintain sterility.

A. Increase the suction pressure as tolerated. B. Flush the tube with 0.9% sodium chloride. C. Replace the NG tube every 24 hr. D. Position the client supine in bed.

Correct Answer is B

Explanation

A) Increase the suction pressure as tolerated: Increasing the suction pressure is not recommended as it can cause damage to the gastric mucosa and lead to complications such as bleeding or ulceration. The suction pressure should be set according to the healthcare provider’s orders and the manufacturer’s guidelines.

B) Flush the tube with 0.9% sodium chloride: Flushing the NG tube with 0.9% sodium chloride is an appropriate action to maintain patency and prevent clogging. This helps ensure that the tube remains functional for effective suction and reduces the risk of complications such as infection or blockage.

C) Replace the NG tube every 24 hr: Replacing the NG tube every 24 hours is unnecessary and can cause discomfort and trauma to the client. NG tubes are typically replaced only when they become clogged, dislodged, or as per the healthcare provider’s orders.

D) Position the client supine in bed: Positioning the client supine in bed is not recommended as it increases the risk of aspiration. The client should be positioned with the head of the bed elevated to reduce the risk of aspiration and promote proper drainage through the NG tube.

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A nurse is caring for an infant who has coarctation of the aorta. Which of the following should the nurse identify as an expected finding?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to perform a sterile dressing change. Which of the following actions should the nurse take when setting up the sterile field?

Correct Answer is C

Explanation

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Correct Answer is B

Explanation

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