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","B","C","D"]
Explanation
Choice A rationale:
Bluish discoloration of the skin, lips, or nail beds (cyanosis) is a classic symptom of cyanotic congenital heart disease (CCHD).
This occurs because of the inadequate oxygenation of the blood, which leads to oxygen-poor blood being circulated in the body.
Choice B rationale:
Poor feeding and inadequate weight gain can be associated with CCHD, especially when there is a significant reduction in cardiac output.
Infants with CCHD may have difficulty feeding due to the increased workload on their heart and may struggle to gain weight.
Choice C rationale:
Rapid breathing and shortness of breath are common symptoms in children with CCHD.
The inadequate oxygenation of the blood can lead to an increased respiratory rate and shortness of breath as the body tries to compensate for the lack of oxygen.
Choice D rationale:
Abnormal heart sounds heard during auscultation are characteristic of CCHD.
The specific type of abnormal heart sound may vary depending on the specific defect but can include murmurs, clicks, or other unusual sounds.
Choice E rationale:
Frequent respiratory infections are not typically associated with CCHD.
While children with CCHD may be more susceptible to infections due to their compromised oxygenation, it is not a direct symptom of the condition.
Correct Answer is A
Explanation
Choice A rationale:
Echocardiography Echocardiography is the most appropriate diagnostic test for assessing the size and shape of the heart and detecting associated abnormalities in a child with a suspected congenital heart defect.
It uses sound waves to create images of the heart, providing detailed information about the heart's structure and function.
It is non-invasive and safe, making it an excellent choice for initial evaluation.
Choice B rationale:
Electrocardiography (ECG) Electrocardiography (ECG) is a valuable test for assessing the electrical activity of the heart, including rhythm and conduction abnormalities.
However, it does not provide detailed information about the size and shape of the heart or structural abnormalities.
ECG is often used in conjunction with other tests like echocardiography.
Choice C rationale:
Chest X-ray A chest X-ray can provide some information about the heart's size and shape but is not as detailed as echocardiography.
It is often used as an initial screening tool but is not the primary diagnostic test for assessing congenital heart defects and their associated abnormalities.
Choice D rationale:
Cardiac catheterization Cardiac catheterization is an invasive procedure that involves threading a thin tube (catheter) through blood vessels into the heart.
It is primarily used to obtain detailed hemodynamic information and to perform interventions such as closing defects or dilating narrowed blood vessels.
While it can be valuable in certain situations, it is not the initial diagnostic test of choice for assessing the size and shape of the heart in a child with a suspected congenital heart defect.
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