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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. A client who received a Mantoux test 48 hr ago and has an induration: The presence of induration is expected in a positive Mantoux test and does not necessarily require follow-up unless the induration is large, indicating possible tuberculosis exposure.
B. A client who is taking warfarin and has started to breastfeed: This situation requires follow-up care. While warfarin can be used during breastfeeding, careful monitoring is needed due to potential effects on the infant and the necessity of maintaining therapeutic INR levels.
C. A client who is taking bumetanide and reports an increase in urinary frequency: This is a normal side effect of bumetanide, a diuretic, and does not require follow-up unless there are additional concerning symptoms.
D. A client who is scheduled for a colonoscopy and is taking sodium phosphate: This is a common preparation for a colonoscopy, and while electrolyte balance should be monitored, it does not inherently indicate a need for follow-up care unless there are specific issues reported.
Correct Answer is B
Explanation
A) Flattening of the artificial airway cuff: This may indicate issues with the cuff pressure or an air leak but does not directly reflect the effectiveness of suctioning.
B) Decreased peak inspiratory pressure: This is the correct answer. A decrease in peak inspiratory pressure suggests that the airway is clearer, allowing for better airflow and indicating that the suctioning was effective in removing secretions that may have caused airway obstruction.
C) Presence of a productive cough: While this can indicate the expulsion of secretions, it may not be a reliable measure of the effectiveness of suctioning in a mechanically ventilated patient, as they may not be able to cough effectively.
D) Thinning of mucous secretions: While thinning secretions can be beneficial, it does not directly indicate that the suctioning itself was effective. The focus should be on airflow and pressure changes.
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