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 C
Explanation
A. Attempt to obtain a throat culture: This is contraindicated because manipulating the throat could exacerbate airway obstruction, leading to a potential respiratory emergency.
B. Use a tongue depressor to observe the back of the throat: This can provoke a spasm or cause complete airway obstruction in a child with epiglottitis and should be avoided.
C. Apply humidified oxygen via a mask: This helps to keep the airways moist and can provide some relief and improve oxygenation while minimizing the risk of airway manipulation.
D. Initiate airborne precautions: Epiglottitis primarily requires droplet precautions, not airborne. Airborne precautions are used for diseases like tuberculosis, which are spread through smaller droplets that remain suspended in the air.
Correct Answer is ["6.4"]
Explanation
Convert the child's weight from pounds to kilograms:
Weight in pounds: 30 lb
Conversion: 1 lb ≈ 0.454 kg
Weight in kg: 30 lb× 0.454 kg/lb =13.62 kg
30lb×0.454kg/lb=13.62kg
Calculate the dose in mg:
Dose: 15 mg/kg
15 mg/kg ×13.62kg=204.3 mg
Determine the volume to administer:
Available concentration: 160 mg/5 mL
Volume in mL:
204.3 mg ÷160 mg/5mL
= 204.3mg×5ml ÷160mg
=6.4mL
The nurse should administer 6.4 mL of acetaminophen.
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