A nurse is caring for an infant diagnosed with Tetralogy of Fallot. The infant has been feeding poorly and has difficulty gaining weight.
What actions should the nurse plan to take? (Select all that apply.)
Administer morphine via IV bolus.
Position the infant in a knee-chest position.
Perform nasopharyngeal suctioning for a maximum of 5 seconds.
Request a prescription for a diuretic.
Administer an additional dose of digoxin.
Prepare to assist with the insertion of a chest tube.
Correct Answer : B,E
Choice A rationale
Administering morphine via IV bolus is not typically a recommended action for an infant diagnosed with Tetralogy of Fallot. While morphine can be used in certain situations to manage pain or anxiety, it is not a specific treatment for the symptoms associated with Tetralogy of Fallot.
Choice B rationale
Positioning the infant in a knee-chest position can be beneficial for infants with Tetralogy of Fallot. This position can help increase blood flow to the lungs, which can improve oxygenation and alleviate symptoms.
Choice C rationale
Performing nasopharyngeal suctioning for a maximum of 5 seconds is not a specific action for an infant diagnosed with Tetralogy of Fallot. While suctioning can be used to clear the airway in certain situations, it does not address the underlying heart defects associated with Tetralogy of Fallot.
Choice D rationale
Requesting a prescription for a diuretic is not typically a recommended action for an infant diagnosed with Tetralogy of Fallot. Diuretics are often used to manage fluid balance in the body, but they do not address the underlying heart defects associated with Tetralogy of Fallot.
Choice E rationale
Administering an additional dose of digoxin can be beneficial for infants with Tetralogy of Fallot. Digoxin is a medication that helps strengthen the heart muscle, enabling it to pump more efficiently. This can help manage symptoms associated with Tetralogy of Fallot.
Choice F rationale
Preparing to assist with the insertion of a chest tube is not a specific action for an infant diagnosed with Tetralogy of Fallot. While a chest tube can be used to manage certain respiratory conditions, it does not address the underlying heart defects associated with Tetralogy of Fallot.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
While it’s true that some changes in the breast, such as dimpling or discharge, can occur with age, these are not normal and could be signs of a serious condition like breast cancer.
Therefore, this instruction should not be included in the pamphlet.
Choice B rationale
While using the palm of the hand to feel for lumps using a circular motion is a common method, it’s not the most effective. The pads of the three middle fingers should be used instead, as they are more sensitive to changes in the breast tissue.
Choice C rationale
This is the correct answer. Performing a breast self-exam in the shower with soapy hands is recommended because the soap helps your fingers glide smoothly over your skin, making it easier to feel for any lumps or changes.
Choice D rationale
While it’s true that women who have a menstrual cycle should perform a breast self-exam every month, the timing suggested here is not accurate. The best time to perform a breast self- exam is a few days after the menstrual period ends, when the breasts are less likely to be tender or swollen.
Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"A"}}
Explanation
- WBC count: This finding is not consistent with either sickle cell anemia or hemophilia. Both conditions do not typically cause an increase in white blood cell count.
- Temperature: This finding is not consistent with either sickle cell anemia or hemophilia. Neither condition is associated with an elevated body temperature unless there is a concurrent infection.
- Bleeding: This finding is consistent with hemophilia. Hemophilia is a bleeding disorder where the blood does not clot properly. This can lead to spontaneous bleeding as well as bleeding following injuries or surgery.
- Reported pain: This finding is consistent with sickle cell anemia. Sickle cell anemia can cause episodes of pain when sickle-shaped red blood cells block blood flow through tiny blood vessels to your chest, abdomen and joints. Pain can also occur in your bones.
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