A nurse is caring for an infant who has tetralogy of Fallot. The infant is crying and is experiencing a hypercyanotic spell. Which of the following actions should the nurse take first?
Administer morphine subcutaneously.
Apply a face mask supplying 100% oxygen.
Attempt to calm and soothe the child.
Place the infant in a knee-chest position.
The Correct Answer is B
Choice A rationale:
Morphine subcutaneously can help reduce anxiety and stress, but supplying oxygen is the priority intervention.
Choice B rationale:
During a hypercyanotic spell ("tet spell"), the infant's oxygen levels drop, leading to cyanosis (blue skin) and distress. Administering oxygen can help improve oxygen saturation and alleviate the spell.
Choice C rationale:
Calming and soothing the child may not be sufficient to address the oxygen saturation issue during a hypercyanotic spell.
Choice D rationale:
Placing the infant in a knee-chest position can help improve blood flow, but administering oxygen should be the initial step.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Appointing the client as a leader may not be appropriate, as individuals with antisocial personality disorder may misuse their position of authority.
Choice B rationale:
Clients with antisocial personality disorder often struggle with interpersonal relationships, may be manipulative, and may engage in behaviors that violate the rights of others. Monitoring the client's interactions with other clients helps ensure a safe and therapeutic environment while preventing harm to others.
Choice C rationale:
Offering warnings before consequences might not be effective with clients who have antisocial personality disorder, as they may disregard rules and consequences.
Choice D rationale:
Assigning a room near the activity area does not necessarily address the need to monitor the client's interactions with others.
Correct Answer is D
Explanation
Choice A rationale:
Filing a transfer request might be considered if the bullying behavior persists despite attempts to address it, but it's important for the newly licensed nurse to initially address the behavior directly.
Choice B rationale:
Discussing the matter with the facility's quality improvement team might be necessary if the situation escalates, but addressing the behavior directly with the coworker is the initial step.
Choice C rationale:
Introducing a no-tolerance policy for incivility is a good idea, but addressing the specific behavior with the coworker is important in the moment.
Choice D rationale:
Calmly addressing the coworker's behavior as soon as it occurs is a proactive way to assert boundaries and address the bullying behavior directly.
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