A practical nurse (PN) is caring for a child who demonstrates "squatting" during play and is admitted for corrective surgery of a congenital heart defect.
Upon rising in the morning, the child demonstrates tachypnea and tachycardia consistent with cyanotic (hypoxic) spells. Which procedure should the PN implement?
Give prescribed digoxin and furosemide.
Return the child to bed and elevate the head of the bed.
Offer to play a board game with the child as a distraction.
Provide oxygen and promote the knee-chest position.
The Correct Answer is D
Choice A rationale
Giving prescribed digoxin and furosemide is part of the long-term management for cardiac conditions, but these medications do not provide immediate relief for an acute hypoxic spell. Digoxin improves cardiac contractility, and furosemide promotes fluid excretion, but their onset of action is not rapid enough for emergent situations.
Choice B rationale
Returning the child to bed and elevating the head of the bed might provide some comfort but does not directly address the underlying physiological cause of the hypoxic spell. Elevating the head of the bed may slightly improve respiratory effort but won't reverse cyanosis effectively.
Choice C rationale
Offering to play a board game with the child as a distraction does not address the physiological emergency of a hypoxic spell. Distraction may be helpful for anxiety but is not an intervention for cyanosis, tachypnea, and tachycardia, which require medical intervention.
Choice D rationale
Providing oxygen increases the available oxygen for gas exchange, and promoting the knee-chest position reduces venous return to the heart, thereby decreasing right-to-left shunting and improving pulmonary blood flow in conditions like Tetralogy of Fallot, which commonly presents with "squatting" and hypoxic spells.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Gravida refers to the total number of pregnancies a woman has had, regardless of outcome. The client has had a pregnancy that resulted in a miscarriage at 16 weeks, a pregnancy that resulted in fetal demise at 31 weeks, and the current pregnancy at 39 weeks. Therefore, the total number of pregnancies is 3. The gravida is 3.
Correct Answer is A
Explanation
Choice A rationale
Acute otitis media is an infection of the middle ear, specifically the air-filled space behind the eardrum. This infection typically results from bacterial or viral invasion, often following an upper respiratory tract infection. It leads to inflammation and fluid accumulation, causing pain and hearing impairment.
Choice B rationale
A drainage out of the outer ear, known as otorrhea, can be a symptom of various ear conditions, including otitis externa (swimmer's ear) or a perforated eardrum with middle ear infection, but it is not the definition of acute otitis media itself.
Choice C rationale
An infection of the inner and outer ear would encompass otitis interna (labyrinthitis) and otitis externa. Acute otitis media specifically refers to the middle ear. While infections can spread, this description is not precise for acute otitis media.
Choice D rationale
A defect of the inner ear relates to structural or functional abnormalities of the cochlea or vestibular system, leading to conditions like sensorineural hearing loss or balance issues. This is a congenital or acquired structural problem, not an infection like acute otitis media.
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