A nurse is assisting in the care of an infant who has congenital heart disease.
Place the infant in a knee chest position
Administer morphine via IV bolus
Provide 100% oxygen by face mask
Request a prescription for a diuretic
Perform nasopharyngeal suctioning for a maximum of 5 seconds
Prepare to assist with the insertion of a chest tube
The Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"B"},"F":{"answers":"B"}}
Place the infant in a knee-chest position: Indicated: ☑️
The knee-chest position is commonly used during a "tet spell," which involves episodes of cyanosis due to decreased oxygen levels. This position increases systemic vascular resistance, which helps redirect blood flow to the lungs, improving oxygenation.
Administer morphine via IV bolus: Indicated: ☑️
Morphine is used to calm the infant, reduce respiratory effort, and decrease pulmonary vascular resistance. It can help in reducing the severity of the tet spell by promoting better oxygenation.
Provide 100% oxygen by face mask: Indicated: ☑️
Administering 100% oxygen can help increase the amount of oxygen in the blood and reduce the effects of hypoxia. Oxygen is a vasodilator and can reduce pulmonary resistance, making it easier for the infant to oxygenate blood.
Request a prescription for a diuretic: Contraindicated: ☑️
Diuretics are generally not indicated in the acute management of tet spells. While they are used in conditions with fluid overload, their use in this context is not beneficial and could potentially worsen the infant's condition by causing dehydration and further reducing blood volume.
Perform nasopharyngeal suctioning for a maximum of 5 seconds: Contraindicated: ☑️
Nasopharyngeal suctioning can be stressful for the infant and may worsen cyanosis or provoke a tet spell due to increased agitation and respiratory effort. It's typically not recommended unless there's a clear indication for airway clearance.
Prepare to assist with the insertion of a chest tube: Contraindicated: ☑️
Chest tube insertion is not a treatment for tet spells or ToF. It is usually indicated for pneumothorax or significant pleural effusions, which are not related to the acute cyanotic episodes seen in ToF. Preparing for this procedure would be inappropriate in this scenario.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. ``Sweating can occur with hypoglycaemia." Sweating is a common symptom of hypoglycemia due to the activation of the sympathetic nervous system. This statement is accurate and does not require clarification.
B. "My son might have nausea and vomiting with hypoglycemia." Nausea and vomiting are typically associated with hyperglycemia and diabetic ketoacidosis (DKA), not hypoglycaemia. Hypoglycaemia usually presents with symptoms like sweating, shakiness, confusion, and hunger. This statement indicates a misunderstanding that needs to be clarified.
C. ``My son might complain of feeling shaky when he has a low blood glucose level." Feeling shaky is a common symptom of hypoglycemia due to the body's response to low blood glucose levels. This statement is correct and does not need clarification.
D. "The onset of low blood glucose usually occurs rapidly." Hypoglycaemia often has a rapid onset, particularly when caused by factors like excessive insulin or missed meals. This statement is accurate and does not require clarification.
Correct Answer is A
Explanation
A. Assist with administering a blood transfusion. Blood transfusions are often necessary in sickle cell crisis to manage severe anemia and improve oxygen delivery to tissues. This action helps alleviate the symptoms of the crisis and prevent complications.
B. Withhold opioids to avoid dependence. Opioids are essential for managing the severe pain associated with sickle cell crises. Concerns about dependence should not prevent adequate pain management in an acute setting.
C. Encourage exercise. During a sickle cell crisis, rest is crucial to reduce oxygen demand and prevent further sickling of red blood cells. Exercise is contraindicated during a crisis.
D. Initiate a 2 L/day fluid restriction. Adequate hydration is critical in managing sickle cell crisis, as it helps prevent further sickling of cells. Fluid restriction is inappropriate and could worsen the condition.
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