A nurse is caring for a preschool client who has Tetralogy of Fallot (TOF). What are the defects the nurse should be aware of when caring for a client with Teratology of Fallot (TOF)? (Select all that apply).
Pyloric Stenosis.
Left Ventricular Hypertrophy. (LVH)
Thickened Right Ventricular Wall
Overriding Aorta.
Ventricular Septal Defect. (MSD)
Pulmonary Stenosis.
Correct Answer : C,D,E,F
A. Pyloric stenosis is unrelated to TOF. It involves the narrowing of the pyloric valve in the stomach and is not a defect associated with TOF.
B. LVH is not typically a feature of TOF, as the primary issues affect the right ventricle.
C. Right ventricular hypertrophy occurs due to the obstruction of blood flow through the pulmonary valve in TOF.
D. In TOF, the aorta is positioned directly over the ventricular septal defect (VSD), which is known as overriding aorta.
E. A VSD is a key component of TOF, where there is a hole between the ventricles, allowing oxygen-poor and oxygen-rich blood to mix.
F. Pulmonary stenosis (narrowing of the pulmonary valve) is one of the hallmark defects in TOF.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. CPR is not typically necessary unless the child stops breathing or the heart stops during the seizure, which is rare.
B. Restraining a child during a seizure can cause injury. The focus should be on safety and protection, not restraint.
C. Lorazepam may be given if the seizure lasts too long, but ensuring safety is the priority action.
D. The nurse’s priority during a seizure is to ensure the child’s safety by removing hazardous items from the area and ensuring the child does not get injured.
Correct Answer is B
Explanation
A. The temperature of the cast is important to check for heat retention but is not the first priority for infection control.
B. Assessing skin integrity around the cast is a priority to detect signs of infection, irritation, or pressure sores.
C. Range of motion is important but should be assessed once the skin and safety around the cast are ensured.
D. While pain level is important, ensuring skin integrity is a higher priority for preventing complications such as infection.
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