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 D
Explanation
Choice A rationale:
An adventitious crisis is a crisis resulting from an external event such as a natural disaster or crime.
Choice B rationale:
Psychopathologic crises involve individuals with preexisting mental health conditions experiencing acute exacerbations.
Choice C rationale:
A psychiatric emergency involves a sudden onset of severe behavioral symptoms that require immediate intervention.
Choice D rationale:
A situational crisis arises from an unexpected life event, such as injury, illness, or loss of independence, which can disrupt a person's normal routine and coping mechanisms.
Correct Answer is C
Explanation
Choice A rationale:
Scheduling appointments earlier in the day accommodates the client's potential "on" periods when Parkinson's symptoms are better controlled.
Choice B rationale:
Looking down at the feet while walking is a technique that can help improve gait and stability, as Parkinson's disease often affects balance.
Choice C rationale:
Thicker liquids are less likely to cause aspiration in individuals with Parkinson's disease, as they can have difficulty coordinating the muscles needed for swallowing.
Choice D rationale:
Constipation is a common issue in Parkinson's disease due to decreased gastrointestinal motility. However, focusing on dietary fiber and fluid intake is preferred before considering laxatives.
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