Following admission for a cardiac catheterization, the nurse is providing discharge teaching to the parents of a 2-year-old toddler with Tetralogy of Fallot. Which instruction should the nurse give the parents if their child becomes pale, cool, and lethargic?

Encourage oral electrolyte solution intake.

Contact their healthcare provider immediately.

Provide a quiet time by holding or rocking the toddler.

Assist the child to a recumbent position.

Answer and Explanation

The Correct Answer is B

Choice A reason: Electrolyte solutions address dehydration but are inappropriate for pale, cool, lethargic symptoms in Tetralogy of Fallot (TOF), indicating a hypercyanotic spell from right-to-left shunting. Urgent medical intervention restores oxygenation, making this inadequate compared to addressing the critical hypoxic episode requiring provider attention.

Choice B reason: Pale, cool, lethargy in TOF signals a hypercyanotic spell, where pulmonary stenosis increases right-to-left shunting, causing cyanosis and hypoxia. Contacting the provider ensures rapid interventions (e.g., oxygen, beta-blockers), preventing cerebral hypoxia or cardiac arrest, addressing the urgent pathophysiological crisis effectively.

Choice C reason: Quiet time by holding or rocking may calm the toddler but does not treat hypoxic spells in TOF, where pale, cool symptoms indicate shunting and hypoxia. Delaying medical intervention risks severe hypoxia, making this less critical than contacting the provider for urgent management.

Choice D reason: A recumbent position worsens TOF’s hypercyanotic spell, increasing venous return and shunting, exacerbating hypoxia. Knee-chest positioning reduces shunting. Contacting the provider is urgent to address pale, cool, lethargic symptoms, ensuring interventions to restore oxygenation, making this position contraindicated.

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Correct Answer is C

Explanation

Choice A reason: Measuring glucose monitors corticosteroid-induced hyperglycemia, but a rigid abdomen with rebound tenderness suggests peritonitis, possibly from IBD-related perforation. Vital signs detect systemic effects like sepsis (e.g., tachycardia), more urgent than glucose, as perforation is a life-threatening emergency requiring immediate intervention to prevent shock.

Choice B reason: Monitoring bloody diarrhea is relevant in IBD, but a rigid abdomen with rebound tenderness indicates peritonitis, likely from perforation. Vital signs assess systemic stability (e.g., fever, hypotension), critical for detecting life-threatening complications like sepsis, making this more urgent than tracking expected IBD symptoms.

Choice C reason: A rigid abdomen with rebound tenderness suggests peritonitis from bowel perforation in IBD, causing peritoneal irritation. Vital signs (e.g., heart rate, BP, temperature) detect shock or infection, guiding urgent interventions like surgery or antibiotics. This assessment prioritizes rapid response to a potentially fatal surgical emergency.

Choice D reason: Encouraging ambulation is contraindicated with a rigid abdomen and rebound tenderness, indicating peritonitis. Movement may worsen peritoneal irritation or infection spread. Vital signs assess systemic compromise, critical for managing perforation, ensuring timely intervention to prevent sepsis or shock, making ambulation inappropriate.

A. Obtain an arterial blood gas (ABG) prior to the procedure. B. Explain that the client may be placed in five positions. C. Perform the drainage immediately after meals. D. Instruct the client to breathe shallow and fast.

Correct Answer is B

Explanation

Choice A reason: Obtaining an ABG assesses oxygenation in COPD but is not needed before postural drainage, which mobilizes secretions. ABGs are invasive, used for exacerbations. Explaining positions prepares the client, enhancing cooperation for effective mucus clearance, addressing airway obstruction without unnecessary invasive testing.

Choice B reason: Postural drainage uses gravity in five positions (e.g., Trendelenburg, lateral) to drain lung segments in COPD, where mucus obstructs airways. Explaining this reduces anxiety, ensuring cooperation, optimizing secretion clearance to improve ventilation and gas exchange, addressing the pathophysiological need for airway clearance.

Choice C reason: Drainage after meals risks aspiration, as a full stomach increases reflux in positions like Trendelenburg. COPD’s mucus retention obstructs airways, and timing drainage appropriately enhances efficacy. Explaining positions ensures effective procedure execution, avoiding complications like aspiration, making this approach unsafe.

Choice D reason: Shallow, fast breathing is contraindicated in COPD, where deep, slow breaths reduce air trapping and improve alveolar ventilation. Postural drainage clears mucus, and proper breathing enhances efficacy. Explaining positions prepares the client, optimizing outcomes, making this instruction incorrect for effective breathing.

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Following admission for a cardiac catheterization, the nurse is providing discharge teaching to the parents of a 2-year-old toddler with Tetralogy of Fallot. Which instruction should the nurse give the parents if their child becomes pale, cool, and lethargic?

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Correct Answer is C

Explanation

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Correct Answer is B

Explanation

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Following admission for a cardiac catheterization, the nurse is providing discharge teaching to the parents of a 2-year-old toddler with Tetralogy of Fallot. Which instruction should the nurse give the parents if their child becomes pale, cool, and lethargic?

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