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.

Answer and Explanation

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

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is D

Explanation

Choice A reason: This statement is correct; early treatment for clubfoot is essential for the best outcomes.

Choice B reason: The parent's understanding of the need for long-term follow-up care until skeletal maturity is accurate.

Choice C reason: Regular visits for new casts are part of the standard treatment protocol for clubfoot.

Choice D reason: This statement indicates a misunderstanding. Clubfoot treatment typically involves a series of casts changed more frequently than 8-10 weeks apart, not a single spica cast for that duration. Further teaching is needed to correct this misconception.

A. Ask the client to choose which medication is needed for the pain. B. Document the client's report of pain in the electronic medical record. C. Compare the client's pain scale rating with the prescribed dosing. D. Determine which prescription will have the quickest onset of action.

Correct Answer is D

Explanation

Choice A reason: Asking the client to choose the medication is not appropriate as the nurse should use clinical judgment to select the medication based on effectiveness and onset of action.
Choice B reason: Documentation is important but should not precede the administration of pain relief.
Choice C reason: Comparing the pain scale rating with prescribed dosing is part of pain management, but the immediate concern is to relieve the pain as quickly as possible.
Choice D reason: This is the correct choice. The nurse should determine which medication will provide the quickest relief from pain, which is the client's immediate need.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which statement by the parent indicates a need for further teaching regarding clubfoot?

Correct Answer is D

Explanation

A postoperative client reports incisional pain. The client has two prescriptions for PRN analgesia that accompanied the client from the postanesthesia unit. Before selecting which medication to administer, which action should the nurse implement?

Correct Answer is D

Explanation

The nurse is giving a health promotion class to adolescents. The nurse will be sure to include information regarding the leading cause of death in adolescents aged 15 and up.

An 17-year-old with a rash and itching in the groin area is concerned that he has contracted a sexually transmitted disease and does not want his parents to find out. The nurse's best response is:

When planning care for a client newly diagnosed with open-angle glaucoma, the nurse identifies a priority nursing problem of visual sensory-perceptual alterations. This problem is based on which etiology?

Which of the following is NOT a risk factor for pediatric mental health disorders such as Attention Deficit Disorder (ADD)/ADHD?

The nurse observes that a client with Parkinson’s disease (PD) has a mask-like face. Which follow-up assessment is most important for the nurse to implement?

A mother brings her two-year-old child to the pediatric office for a sick visit. The child is seen regularly at the office and was last seen at her well-child visit two months ago. Based on this information, which is the most appropriate action by the nurse?

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?

A child is diagnosed with sickle cell disease. The parents are unsure how their child contracted the disease. Which explanation by the nurse is the most appropriate?