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?
Upper extremity hypotension
Weak femoral pulses
Frequent nosebleeds
Increased intracranial pressure
The Correct Answer is B
A. Coarctation of the aorta typically results in hypertension in the upper extremities due to increased pressure proximal to the coarctation.
B. Weak or absent femoral pulses are characteristic findings in coarctation of the aorta due to reduced blood flow to the lower extremities beyond the coarctation. This finding indicates peripheral vascular compromise in the lower limbs.
C. Frequent nosebleeds are not typically associated with coarctation of the aorta.
D. Coarctation of the aorta does not directly affect intracranial pressure.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. While revising the current policy for catheter care may be necessary, it is not the first step in addressing the increase in infections. Understanding the factors contributing to the infections is crucial before policy revision.
B. Identifying possible precipitating factors related to the infections is the first step in addressing the issue. This involves investigating the circumstances surrounding the infections to determine potential causes and contributing factors.
C. While staff training is important, scheduling training before understanding the root cause of the infections may not effectively address the problem.
D. Meeting with providers to discuss measures to decrease infections may be necessary, but it should occur after identifying the precipitating factors to ensure targeted and effective interventions.
Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"B"}}
Explanation
A. Clamping the chest tube during ambulation can lead to increased intrathoracic pressure, which may cause tension pneumothorax or other complications. Chest tubes should remain unclamped to maintain proper drainage. However, it may be done briefly during tube changes or if there is a suspected air leak, always under specific medical orders.
B. Burning pain in the chest could indicate complications such as infection or irritation at the insertion site. Reporting this symptom to the provider allows for timely assessment and intervention.
C. A loose dressing around the chest tube can compromise the integrity of the system, leading to air leaks or contamination. Reinforcing the dressing helps maintain a sterile environment and prevents dislodgement of the tube.
D. Maintaining the appropriate water seal level in the chest drainage system is essential for proper functioning. This prevents air from entering the pleural space while allowing drainage to occur effectively.
E. Stripping or milking the chest tube is no longer a recommended practice as it can cause damage to the tissues and lead to airway obstruction or clot formation. Instead, gentle manipulation or rotation of the tubing may be done if there are signs of occlusion, but routine stripping is not recommended
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