A nurse is caring for an infant who has Tetralogy of Fallot and notes that the infant is easily fatigued when eating. Which defect is not present in this cardiac congenital malformation?
Overriding aorta
Pulmonary stenosis
Left ventricular hypertrophy
Ventricular septal defect
The Correct Answer is C
A. Overriding aorta: In Tetralogy of Fallot, the aorta is positioned over the ventricular septal defect (VSD), rather than solely over the left ventricle as it would be in a normal heart. This is called overriding aorta, which allows blood from both the right and left ventricles to enter the aorta.
B. Pulmonary stenosis: This is a critical component of Tetralogy of Fallot. Pulmonary stenosis refers to narrowing of the pulmonary valve or the area just below it, which restricts blood flow from the right ventricle to the pulmonary artery. This results in decreased blood flow to the lungs for oxygenation.
C. Left ventricular hypertrophy: This choice is not typically associated with Tetralogy of Fallot. Left ventricular hypertrophy refers to an enlargement or thickening of the muscular wall of the left ventricle of the heart. It is often seen in conditions where the left ventricle has to work harder to pump blood, such as in hypertension or aortic stenosis, but it is not a characteristic feature of Tetralogy of Fallot.
D. Ventricular septal defect: This defect is one of the four components of Tetralogy of Fallot. A ventricular septal defect (VSD) is a hole in the septum, the muscular wall that separates the left and right ventricles of the heart. In Tetralogy of Fallot, the VSD allows oxygen-poor blood from the right ventricle to flow directly into the left ventricle and out to the body.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Drink eight glasses of fluid daily: This is crucial advice for patients with sickle cell anemia, as adequate hydration helps prevent sickling of red blood cells and reduces the risk of vaso-occlusive crises. Therefore, this precaution is appropriate and should be included in discharge teaching.
B. Maintain an updated Haemophilus influenzae type b (Hib) immunization: While vaccination is essential for overall health, maintaining Hib immunization is not directly related to sickle cell anemia or vaso-occlusive crises. However, it's still important for the child's general well-being and should be addressed but may not be the priority in discharge teaching for sickle cell anemia.
C. Avoid playground activities at school: Children with sickle cell anemia are at risk of vaso-occlusive crises triggered by dehydration, fatigue, or extreme physical exertion. While playground activities can be strenuous, completely avoiding them may not be necessary. Instead, the child should be educated on the importance of staying hydrated, taking breaks when needed, and avoiding excessive physical strain.
D. Assume postural drainage positions every 6 hours: Postural drainage is not typically indicated for sickle cell anemia or vaso-occlusive crises unless there are specific respiratory complications. This precaution is not relevant to the management of sickle cell anemia and should not be included in discharge teaching for this condition.
Correct Answer is C
Explanation
A. Administer the medication at mealtime.Ferrous sulfate is best absorbed on an empty stomach because food, especially those rich in calcium or tannins, can interfere with its absorption. Administering it with meals reduces its effectiveness.
B.While bedtime administration is not contraindicated, it is not necessary. The timing of administration should focus on maximizing absorption, typically between meals or on an empty stomach.
C. Ferrous sulfate can stain teeth if taken orally in liquid form. Using a straw minimizes contact with teeth, reducing the risk of discoloration. Parents should also be advised to encourage the child to rinse their mouth after taking the medication.
D. Dilute the medication with 240 mL of milk. Milk contains calcium, which inhibits the absorption of iron. Ferrous sulfate should not be taken with milk or dairy products to ensure optimal absorption.
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