A client diagnosed with Tetralogy of Fallot (TOF) presents with cyanosis that worsens with crying or feeding; clubbing of fingers and toes; poor feeding, weight gain, or growth; polycythemia; hypercyanotic spells (“tet spells”).
What should be the nurse's immediate response?
Administer oxygen therapy immediately.
Prepare for emergency surgery.
Monitor vital signs closely.
Administer prescribed medication.
The Correct Answer is B
Prepare for emergency surgery.
Choice A rationale:
Administer oxygen therapy immediately.
Administering oxygen therapy would provide temporary relief to the patient's cyanosis, but it does not address the underlying issue in Tetralogy of Fallot (TOF).
TOF is a congenital heart defect characterized by a combination of four heart abnormalities, one of which is a ventricular septal defect (VSD) that allows oxygen-poor blood to mix with oxygen-rich blood.
Administering oxygen will increase the oxygen saturation in the blood but will not fix the structural problem.
The immediate priority for a patient with TOF experiencing a hypercyanotic spell is to address the heart defect itself.
Choice B rationale:
Prepare for emergency surgery.
In Tetralogy of Fallot, hypercyanotic spells, also known as "tet spells," are a medical emergency.
These spells occur due to a sudden decrease in systemic vascular resistance, causing more blood to flow into the right ventricle, leading to increased right-to-left shunting, further decreasing oxygenation.
The most appropriate intervention is to prepare for emergency surgery to correct the underlying cardiac defects, such as closing the VSD and relieving right ventricular outflow obstruction.
Surgery is the definitive treatment for TOF and should be performed promptly during a tet spell to prevent severe hypoxia and potential long-term complications.
Choice C rationale:
Monitor vital signs closely.
While monitoring vital signs is essential in the care of a patient with TOF, it is not the most immediate response in the scenario of a hypercyanotic spell.
Monitoring alone will not address the critical need for intervention to improve oxygenation and prevent hypoxia.
Choice D rationale:
Administer prescribed medication.
Administering prescribed medication may be part of the overall management of a patient with TOF, but it is not the immediate response during a hypercyanotic spell.
Medications can help manage symptoms and stabilize the patient, but the definitive treatment for TOF is surgical correction.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
The nurse's response should include teaching proper positioning techniques as optimizing a child's respiratory function can be improved by correct positioning.
Proper positioning helps ensure that the child's airways are open and not obstructed, which is essential for effective breathing.
This is a fundamental aspect of respiratory care, especially in pediatric patients who may not be able to reposition themselves if they are uncomfortable or experiencing difficulty breathing.
Choice B rationale:
Administering vasodilators is not typically a measure to optimize a child's respiratory function.
Vasodilators are medications that dilate blood vessels and are usually used in specific cardiovascular conditions to reduce the workload on the heart.
They are not directly related to optimizing respiratory function.
Choice C rationale:
Monitoring growth patterns, while important for a child's overall health, is not a direct response to the client's question about optimizing respiratory function.
Growth patterns are assessed for general development and health, but they do not specifically address respiratory function.
Choice D rationale:
Providing information on the child's condition is essential, but it does not directly address the question about optimizing respiratory function.
While education is crucial, the primary focus should be on practical measures to improve the child's respiratory function, such as proper positioning and breathing techniques.
Correct Answer is A
Explanation
Choice A rationale:
The patient's statement, "My baby's skin and lips have turned bluish," is a classic symptom of cyanosis.
Cyanosis is a bluish or purple discoloration of the skin and mucous membranes, which occurs due to a lack of oxygen in the blood.
In this case, it's associated with a ventricular septal defect (VSD), which is a congenital heart defect that allows oxygen-poor blood from the right side of the heart to mix with oxygen-rich blood from the left side.
Choice B rationale:
The statement, "My baby has difficulty feeding and is not gaining weight properly," may be related to the VSD, but it is not a typical symptom of cyanosis.
This symptom can occur due to congestive heart failure in infants with VSD.
Choice C rationale:
"My baby gets tired quickly during physical activity" can also be associated with VSD and congestive heart failure, but it is not a direct symptom of cyanosis.
Choice D rationale:
"I can hear abnormal heart sounds during the check-up" is not a symptom but rather a sign of a ventricular septal defect.
Abnormal heart sounds, like a loud holosystolic murmur, may be heard on auscultation.
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