An 8-month-old infant has a hyper-cyanotic Tet spell while blood is being drawn. Which of the following should the nurse's first action be?
Prepare the family for the child's imminent death
Begin cardiopulmonary resuscitation compressions
Assess for neurologic defects
Administer oxygen by face mask
The Correct Answer is D
A. Preparing the family for imminent death is premature and inappropriate as the first action. Hyper-cyanotic spells (Tet spells) are medical emergencies but often reversible with prompt intervention.
B. CPR is not the first response unless the child is unresponsive and pulseless. Tet spells are managed with specific interventions to reduce hypoxia.
C. Assessing for neurological defects may be important later, but during an acute Tet spell, the priority is to restore oxygenation and stabilize the child.
D. The first action during a Tet spell is to administer oxygen to reduce pulmonary vasoconstriction and improve oxygenation. This is often followed by placing the child in a knee-chest position, giving morphine, and preparing for further medical support as needed. Oxygen is the most immediate, non-invasive intervention.
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Related Questions
Correct Answer is D
Explanation
A. Preparing the family for imminent death is premature and inappropriate as the first action. Hyper-cyanotic spells (Tet spells) are medical emergencies but often reversible with prompt intervention.
B. CPR is not the first response unless the child is unresponsive and pulseless. Tet spells are managed with specific interventions to reduce hypoxia.
C. Assessing for neurological defects may be important later, but during an acute Tet spell, the priority is to restore oxygenation and stabilize the child.
D. The first action during a Tet spell is to administer oxygen to reduce pulmonary vasoconstriction and improve oxygenation. This is often followed by placing the child in a knee-chest position, giving morphine, and preparing for further medical support as needed. Oxygen is the most immediate, non-invasive intervention.
Correct Answer is D
Explanation
A. Children with CF are at risk for dehydration due to excessive salt loss in sweat, so adequate fluid intake is essential, not restriction.
B. Children with CF require high-calorie, high-fat, and high-protein diets to support growth and compensate for malabsorption. Low-fat, low-protein diets are inappropriate.
C. Sodium loss through sweat is significant in CF, especially in hot weather, so salt intake should not be restricted—in fact, extra salt may be needed.
D. Pancreatic insufficiency in CF leads to malabsorption of fats and proteins. Administering pancreatic enzymes with all snacks and meals aids digestion and improves nutrient absorption, which is essential for growth and weight maintenance.
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