A nurse is caring for an infant diagnosed with Tetralogy of Fallot. The infant has been feeding poorly and has difficulty gaining weight.

What actions should the nurse plan to take? (Select all that apply.)

Administer morphine via IV bolus.

Position the infant in a knee-chest position.

Perform nasopharyngeal suctioning for a maximum of 5 seconds.

Request a prescription for a diuretic.

Administer an additional dose of digoxin.

Prepare to assist with the insertion of a chest tube.

Answer and Explanation

Correct Answer : B,E

Choice A rationale
Administering morphine via IV bolus is not typically a recommended action for an infant diagnosed with Tetralogy of Fallot. While morphine can be used in certain situations to manage pain or anxiety, it is not a specific treatment for the symptoms associated with Tetralogy of Fallot.
Choice B rationale
Positioning the infant in a knee-chest position can be beneficial for infants with Tetralogy of Fallot. This position can help increase blood flow to the lungs, which can improve oxygenation and alleviate symptoms.
Choice C rationale
Performing nasopharyngeal suctioning for a maximum of 5 seconds is not a specific action for an infant diagnosed with Tetralogy of Fallot. While suctioning can be used to clear the airway in certain situations, it does not address the underlying heart defects associated with Tetralogy of Fallot.
Choice D rationale
Requesting a prescription for a diuretic is not typically a recommended action for an infant diagnosed with Tetralogy of Fallot. Diuretics are often used to manage fluid balance in the body, but they do not address the underlying heart defects associated with Tetralogy of Fallot.
Choice E rationale
Administering an additional dose of digoxin can be beneficial for infants with Tetralogy of Fallot. Digoxin is a medication that helps strengthen the heart muscle, enabling it to pump more efficiently. This can help manage symptoms associated with Tetralogy of Fallot.
Choice F rationale
Preparing to assist with the insertion of a chest tube is not a specific action for an infant diagnosed with Tetralogy of Fallot. While a chest tube can be used to manage certain respiratory conditions, it does not address the underlying heart defects associated with Tetralogy of Fallot.

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Correct Answer is D

Explanation

Choice A rationale
While gastrointestinal symptoms can occur in Kawasaki disease, such as diarrhea, vomiting, and abdominal pain, the primary system affected is not the gastrointestinal system.
Choice B rationale
Although Kawasaki disease can cause symptoms such as a rash and changes in the lips and oral cavity, which are related to the integumentary system, the primary system affected is not the integumentary system.
Choice C rationale
Respiratory symptoms are not typically a primary concern in Kawasaki disease. While a child with Kawasaki disease may have some respiratory symptoms such as a cough and runny nose, these are not the main focus of monitoring.
Choice D rationale
Kawasaki disease is a systemic vasculitis that predominantly affects the cardiovascular system. It is the leading cause of acquired heart disease in children. Therefore, monitoring the cardiovascular system is crucial in managing a child with Kawasaki disease.

A. Restrain the client. B. Place the client in a side-lying position. C. Place a tongue depressor in the client’s mouth. D. Assess the client’s airway patency. E. Remove objects from the client’s bed.

Correct Answer is ["B","D","E"]

Explanation

Choice A rationale
Restraining a child during a seizure is not recommended. It does not stop the seizure and can lead to injury. The child’s movements during a seizure are involuntary, so trying to stop them can cause harm.
Choice B rationale
Placing the child in a side-lying position is recommended during a seizure. This position helps to prevent aspiration, which can occur if the child vomits during the seizure.
Choice C rationale
It is a common misconception that a person having a seizure can swallow their tongue, but this is not true. Attempting to place a tongue depressor or any other object in the child’s mouth during a seizure can cause injury to the child’s teeth or jaw.
Choice D rationale
Assessing the child’s airway patency is crucial during a seizure. Seizures can cause changes in breathing patterns and can potentially lead to respiratory distress. Therefore, monitoring the child’s breathing during a seizure is important.
Choice E rationale
Removing objects from the child’s bed or surrounding area can help prevent injury during a seizure. During a seizure, the child may have uncontrolled movements, and removing nearby objects can help ensure the child’s safety.

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A nurse is caring for an infant diagnosed with Tetralogy of Fallot. The infant has been feeding poorly and has difficulty gaining weight. What actions should the nurse plan to take? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a child who has Kawasaki disease. Which of the following systems should the nurse monitor in response to this diagnosis?

Correct Answer is D

Explanation

A nurse is caring for a child who is having a seizure. Which of the following actions should the nurse take? (Select all that apply.)

Correct Answer is ["B","D","E"]

Explanation

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A nurse is caring for an infant diagnosed with Tetralogy of Fallot. The infant has been feeding poorly and has difficulty gaining weight.

What actions should the nurse plan to take? (Select all that apply.)