An infant with tetralogy of Fallot is having a hypercyanotic episode ('tet' spell). Which three nursing interventions are appropriate for the nurse to implement for this infant?
Administer oxygen.
Place the infant in Trendelenburg position.
Draw blood for a serum hemoglobin.
Place the infant in knee-chest position.
Administer morphine as ordered.
Correct Answer : A,D,E
Choice A reason: Administering oxygen helps increase the oxygen saturation during a 'tet' spell.
Choice B reason: The Trendelenburg position is not recommended for 'tet' spells as it does not help alleviate the hypercyanotic episode.
Choice C reason: While important for overall assessment, drawing blood for serum hemoglobin is not an immediate intervention during a 'tet' spell.
Choice D reason: Placing the infant in a knee-chest position increases systemic vascular resistance, which can help improve oxygenation.
Choice E reason: Administering morphine is appropriate as it helps to relax the infant, reducing the work of breathing and improving oxygenation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: This is the correct choice. Diabetes insipidus is characterized by the inability to concentrate urine, leading to excessive urination and a risk of dehydration and hypernatremia (high sodium levels).
Choice B reason: Hyperglycemia is associated with diabetes mellitus, not diabetes insipidus.
Choice C reason: Hypoglycemia (low blood sugar) is not a typical finding in diabetes insipidus.
Choice D reason: Hypercalcemia (high calcium levels) is not directly related to diabetes insipidus.
Correct Answer is C
Explanation
Choice A reason: Keeping alarm levels low is important to reduce stress and promote a healing environment, but it is not the most impactful intervention for personalized care.
Choice B reason: Dimming the lights at night helps maintain a normal sleep-wake cycle, which is beneficial but not as specific to the client's individual needs as continuity of care.
Choice C reason: Having the same nurses care for the patient on consecutive days can provide consistency and build trust, which is especially important for a child in critical condition.
Choice D reason: While visits from school friends can be uplifting, they may not be feasible or appropriate for a client in critical condition in the PICU. The priority is ensuring stable and consistent care.
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