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.

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Correct Answer is A

Explanation

Choice A reason: This is the correct choice. An 8-year-old is typically capable of understanding and using PCA effectively, especially after a major surgery like spinal fusion.
Choice B reason: A 6-year-old may not fully understand how to use PCA and could be at risk for under or overdosing.
Choice C reason: While a 10-year-old could use PCA, the presence of a concussion may impair their ability to use it properly.
Choice D reason: A 16-year-old with Down Syndrome may have cognitive impairments that could hinder the safe use of PCA.

A. A 5-year-old who is unable to zip his own jacket. B. A 2-year-old who cannot recite her phone number. C. A 6-year-old who is unable to sit still for a short story. D. A 2-year-old who is unable to cut with scissors. E. An 18-month-old toddler who is unable to phrase sentences.

Correct Answer is C

Explanation

Choice A reason: This choice is incorrect. It is not unusual for a 5-year-old to have difficulty with zippers.
Choice B reason: This choice is incorrect. Reciting a phone number is not expected of a 2-year-old.
Choice C reason: This is one of the correct choices. A 6-year-old should be able to sit still for a short story, and difficulty doing so may indicate a developmental delay.
Choice D reason: This choice is incorrect. A 2-year-old typically does not have the fine motor skills to cut with scissors.
Choice E reason: This is one of the correct choices. An 18-month-old should be starting to phrase simple sentences, and the inability to do so may indicate a developmental delay.

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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

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