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.
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Related Questions
Correct Answer is D
Explanation
Choice A reason: While monitoring blood pressure and symptoms is important, it is not a self-management outcome.
Choice B reason: Taking up to 4 nitroglycerine tablets may be part of the treatment plan, but it is not an outcome.
Choice C reason: Encouraging daily exercise is good, but it does not address the management of chest pain on exertion.
Choice D reason: This is the correct choice. Recording episodes of angina and self-management strategies provides valuable information for adjusting treatment and empowering the patient.
Correct Answer is A
Explanation
Choice A reason: This is the correct choice. Rheumatic fever is often preceded by an upper respiratory infection caused by group A Streptococcus, which can lead to a sore throat.
Choice B reason: Chest trauma and a fractured rib are not related to the development of rheumatic fever.
Choice C reason: Although a pre-existing heart defect can increase the risk of complications, it is not the cause of rheumatic fever.
Choice D reason: A decreasing appetite over several months is not specifically indicative of rheumatic fever.
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