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 C

Explanation

Choice A reason: This statement is not accurate and may cause unnecessary distress, as Guillain-Barré Syndrome often does not result in a lifelong prognosis.

Choice B reason: This statement is overly optimistic and may not be accurate, as recovery times can vary greatly between individuals.

Choice C reason: This response provides a realistic expectation without causing undue alarm, acknowledging the temporary nature of the paralysis and the potential duration of recovery.

Choice D reason: While sensory loss can occur, it is not guaranteed, and the focus should be on the respiratory paralysis and the recovery process.

A. Discuss with the family the child's previous history of injury. B. Consult with the practitioner about what analgesia can be safely administered. C. Explain that analgesia may mask signs of a decreasing level of consciousness. D. Teach the family that adjunctives such as benzodiazepines are preferred for head injuries.

Correct Answer is B

Explanation

Choice A reason: Discussing the child's previous history of injury is important, but it does not address the immediate concern of pain management.

Choice B reason: Consulting with a practitioner to determine safe analgesia options is crucial for managing pain while also monitoring the child's variable consciousness levels.

Choice C reason: While it is true that analgesia can mask neurological symptoms, it is essential to manage pain effectively, and the healthcare team can monitor for changes in consciousness.

Choice D reason: Teaching the family about specific medications like benzodiazepines is not the most immediate concern and should be left to the practitioner's discretion based on the child's condition. Pain management and safety are the priorities.

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

What is the best response by the nurse when the parents ask about the paralysis associated with Guillain-Barré Syndrome, which has affected the respiratory muscles and requires mechanical ventilation for their child?

Correct Answer is C

Explanation

Which is the most appropriate nursing action for a school-age child who has sustained a head injury and multiple fractures after being thrown from a horse and whose level of consciousness is variable?

Correct Answer is B

Explanation

Which intervention should be implemented for a school-age client admitted to the pediatric intensive care unit (PICU) in critical condition after a motor vehicle accident?

The nurse is planning care for an infant after a cleft-lip repair. Which of the following is NOT an appropriate nursing intervention for this infant?

Which of the following best describes hypopituitarism?

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.

What is the highest priority nursing diagnosis for a pediatric client with a third-degree circumferential burn of the right arm?

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

Which two interventions are considered supportive care for a family whose infant has died from sudden infant death syndrome (SIDS)?