Exhibits
Review H and P, nurse's note, and laboratory results.
Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.
The Correct Answer is []
Potential Condition
Polycythemia
Tetralogy of Fallot, a congenital heart condition, often leads to decreased oxygenation, which triggers the body to produce more red blood cells to compensate, resulting in polycythemia.
Actions the nurse should take:
Take the child’s vital signs: Monitoring vital signs is essential to assess the child's overall stability and detect any signs of distress or hypoxia.
Ask the child’s parents about the frequency of tet spells: Tet spells (hypercyanotic episodes) are common in children with Tetralogy of Fallot, and understanding their frequency helps assess the child's current condition and plan interventions.
Parameters to monitor:
Oxygen saturation: Monitoring oxygen levels is crucial to determine how well the child is oxygenating and to detect any hypoxia or cyanosis.
Weight: Monitoring weight is important in this child, who is in the lower percentiles for growth, as poor weight gain may indicate the need for nutritional or medical intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Monitoring for urinary incontinence may be important but is not the priority in the context of weight management and post-surgical care for gastroplasty.
B. Clients undergoing bariatric surgery are at increased risk for depression due to changes in body image and lifestyle. Observing for signs of depression is crucial to support the client’s mental health and ensure adherence to the postoperative plan.
C. While providing a wide variety of meal choices can be helpful, it is more important to ensure that the client’s psychological needs are addressed first.
D. Applying sequential compression stockings is important for preventing venous thromboembolism but is not the most critical intervention related to the client's specific context of weight management and mental health.
Correct Answer is B
Explanation
A. Continue to provide life support until a thorough search for a guardian is completed: While continuing life support is essential, the delay involved in waiting for a guardian to be located could jeopardize the patient's life. Immediate surgery is necessary to save the client, and life support is unlikely to be sufficient on its own.
B. Carry on with surgical preparation of the client without a signed informed consent: In cases of medical emergencies where the patient is unable to provide consent (such as being unresponsive), the healthcare team can proceed with necessary life-saving procedures without waiting for formal written consent. The principle of implied consent applies in this scenario, where it is assumed the patient would consent to life-saving treatment if they were able to do so.
C. Ask the client's friend to sign the informed consent since the client is unresponsive: The friend does not have the legal authority to provide informed consent unless they are a legal guardian or have been granted specific decision-making powers. Consent should not be obtained from a non-guardian in this situation.
D. Notify the unit manager that an emergency court order is needed to allow surgery: While emergency court orders can sometimes be used in certain legal situations, they are unnecessary when the immediate need for life-saving surgery overrides the formalities of obtaining a signed consent. The focus should be on proceeding with treatment to preserve life.
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