The nurse if giving instructions to parents of a 4-month-old infant with tetralogy of fallot. An important teaching point should include:
Add rice cereal to her formula to increase her calories
If the infant becomes blue and is breathing deeply, put her in the knee-chest position
If the infant becomes blue and is breathing deeply, put her in trendelenburg position
Feed the infant every 2 hours around the clock.
The Correct Answer is B
A. Adding rice cereal could cause excess work on the heart and worsen symptoms. The focus should be on low-stress feeding.
B. Knee-chest position increases systemic vascular resistance, which helps relieve hypercyanotic spells (tet spells) in infants with tetralogy of Fallot.
C. Trendelenburg position is not effective for relieving cyanosis in this condition.
D. The infant with tetralogy of Fallot should be fed smaller, more frequent meals rather than every 2 hours.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Insulin shock is another term for hypoglycemia, which would not cause unconsciousness after refusing insulin.
B. The history of missed insulin and high-carb intake suggests diabetic ketoacidosis (DKA), where lack of insulin leads to the breakdown of fats, creating ketones and resulting in unconsciousness.
C. An insulin reaction is hypoglycemia, which typically causes shakiness, sweating, and confusion, not unconsciousness after high-carb intake.
D. Metabolic alkalosis is unlikely in this case and is not related to missed insulin or high blood sugar.
Correct Answer is D
Explanation
A. Giving an extra dose after a missed dose can lead to toxicity. Parents should skip the missed dose and not give two doses at once.
B. Digoxin should not be mixed with formula because it may affect the absorption of the medication.
C. If the child vomits, do not administer another dose. The nurse should instruct parents to monitor for vomiting and hold the dose if needed.
D. Giving the medication at regular intervals ensures consistent therapeutic levels and reduces the risk of toxicity.
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