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 A
Explanation
Choice A rationale:
The client is experiencing signs of an allergic reaction or anaphylaxis, which can be life-threatening. The rapid response team should be called to provide immediate medical assistance.
Choice B rationale:
Intubation is not the immediate priority. Addressing the allergic reaction and ensuring the client's airway, breathing, and circulation are the first steps.
Choice C rationale:
Obtaining an arterial blood gas (ABG) level is not the priority when the client is experiencing respiratory distress and facial swelling.
Choice D rationale:
Administering diphenhydramine may be part of the treatment plan, but the immediate priority is to call for emergency assistance to manage the allergic reaction.
Correct Answer is A
Explanation
Choice A rationale:
Placing objects within the client's reach on the right side helps to compensate for the hemiparesis and facilitates the client's ability to independently access items.
Choice B rationale:
Encouraging the client to repeat phonetic sounds might be more appropriate for speech therapy and may not directly address hemiparesis.
Choice C rationale:
Pausing to allow the client time to respond to questions is a communication technique but does not address the physical effects of hemiparesis.
Choice D rationale:
Frequently orienting the client to time, place, and surroundings is important for cognitive support but does not specifically address hemiparesis.
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