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A nurse is caring for an infant who has congenital heart disease.

Which of the following actions should the nurse plan to take? Please select 3 actions. (Select all that apply.)

Administer morphine via IV bolus.

Prepare to assist with the insertion of a chest tube.

Place the infant in a knee-chest position.

Request a prescription for a diuretic.

Administer an additional dose of digoxin.

Perform nasopharyngeal suctioning for a maximum of 5 seconds.

Provide 100% oxygen by face mask.

Answer and Explanation

Correct Answer : A,C,G

A. Administer morphine via IV bolus: Morphine is often used in infants with congenital heart defects, such as Tetralogy of Fallot, to reduce agitation, anxiety, and improve oxygenation by reducing systemic vascular resistance. However, this should be done cautiously, as it can decrease respiratory drive and should be administered per specific provider orders.

B. Prepare to assist with the insertion of a chest tube: A chest tube would not be indicated at this moment unless there is evidence of a pneumothorax, hemothorax, or pleural effusion. This scenario does not suggest these conditions.

C. Place the infant in a knee-chest position: This is a classic intervention for infants with Tetralogy of Fallot during a hypercyanotic spell. The knee-chest position increases systemic vascular resistance and reduces the right-to-left shunting of blood, helping to improve oxygenation and reduce cyanosis.

D. Request a prescription for a diuretic: Diuretics are commonly used in infants with congenital heart disease, including Tetralogy of Fallot, to manage fluid retention. This is important for controlling symptoms of heart failure, which may exacerbate cyanosis and respiratory distress.

E. Administer an additional dose of digoxin: While digoxin is used to manage heart failure in infants with congenital heart defects, there is no indication that the infant is in heart failure at this moment, and additional digoxin should only be administered with a provider's order, based on specific clinical needs.

F. Perform nasopharyngeal suctioning for a maximum of 5 seconds: Suctioning should only be performed if the infant is visibly obstructed or struggling with airway clearance. Prolonged or unnecessary suctioning could lead to further agitation and hypoxia in this infant.

G. Provide 100% oxygen by face mask: While oxygen alone isn't always fully effective in tet spells due to the shunting of blood, it's still an important intervention to maximize available oxygen.

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Correct Answer is D

Explanation

A. Polyuria is more commonly seen in hyperglycemia, not hypoglycemia, so it is unlikely to be present with a blood glucose level of 55 mg/dL.

B. Dry, flushed skin is typically a sign of hyperglycemia (e.g., in diabetic ketoacidosis), not hypoglycemia.

C. Deep, rapid respirations are a symptom of metabolic acidosis or severe hyperglycemia, not hypoglycemia.

D. Tachycardia is a common compensatory response to hypoglycemia, as the body tries to increase glucose delivery to tissues.

A. Provide a daily session with a play therapist. B. Discourage visits from the client's friends. C. Vary the child's schedule each day. D. Encourage the client to complete school work.

Correct Answer is D

Explanation

A. While play therapy can be beneficial, it is not the most relevant action for a 10-year-old child in this context.

B. Discouraging visits from friends can lead to feelings of isolation and is not aligned with Erikson's stage of industry vs. inferiority, where children need opportunities for social interaction.

C. A consistent routine is important for children to feel secure and reduce anxiety.

D. Encouraging the child to continue with schoolwork fosters a sense of accomplishment and helps maintain normalcy, promoting their psychosocial development.

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A nurse is caring for an infant who has congenital heart disease. Which of the following actions should the nurse plan to take? Please select 3 actions. (Select all that apply.)

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Naxlex Comprehensive Predictor Exams

Correct Answer is D

Explanation

A nurse is planning care for a 10-year-old child who will be hospitalized for an extended period of time. Which of the following actions should the nurse include in the plan of care to meet the client's psychosocial needs according to Erikson?

Correct Answer is D

Explanation

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A nurse is caring for an infant who has congenital heart disease.

Which of the following actions should the nurse plan to take? Please select 3 actions. (Select all that apply.)