An infant with tetralogy of Fallot is having a hypercyanotic episode ('tet' spell). Which three nursing interventions are appropriate for the nurse to implement for this infant?

Administer oxygen.

Place the infant in Trendelenburg position.

Draw blood for a serum hemoglobin.

Place the infant in knee-chest position.

Administer morphine as ordered.

Answer and Explanation

Correct Answer : A,D,E

Choice A reason: Administering oxygen helps increase the oxygen saturation during a 'tet' spell.
Choice B reason: The Trendelenburg position is not recommended for 'tet' spells as it does not help alleviate the hypercyanotic episode.
Choice C reason: While important for overall assessment, drawing blood for serum hemoglobin is not an immediate intervention during a 'tet' spell.
Choice D reason: Placing the infant in a knee-chest position increases systemic vascular resistance, which can help improve oxygenation.
Choice E reason: Administering morphine is appropriate as it helps to relax the infant, reducing the work of breathing and improving oxygenation.

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Correct Answer is B

Explanation

Choice A reason: IV fluid replacement in DKA is typically isotonic, not hypertonic, to avoid rapid changes in osmolality.
Choice B reason: This is correct. While the total body potassium is depleted in DKA, the initial lab values often show hyperkalemia (high potassium) due to the metabolic acidosis, which shifts potassium out of the cells. This can lead to serious cardiac dysrhythmias and even cardiac arrest, making continuous cardiac monitoring and potassium level assessment a top priority.
Choice C reason: Monitoring for hypertension is important, but the primary concern in DKA is managing the acidosis and hyperglycemia.
Choice D reason: This is incorrect. Treatment for DKA involves a continuous IV infusion of regular insulin at a low, steady rate, not high doses of NPH insulin. NPH insulin is an intermediate-acting insulin and is not suitable for the acute management of DKA.

A. 8 oz of apple or orange juice, three times per day. B. 24-32 oz of whole cow's milk per day. C. Meats, eggs, and green vegetables. D. Fruits, whole grains, and rice.

Correct Answer is C

Explanation

Choice A reason: While vitamin C in juices can enhance iron absorption, they are not sufficient sources of iron by themselves.
Choice B reason: Cow's milk can interfere with iron absorption and is not recommended in high quantities for a child with anemia.
Choice C reason: This is the correct choice. These foods are rich in iron, which is essential for treating anemia.
Choice D reason: These are healthy options but do not provide the necessary iron content to effectively address anemia.

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An infant with tetralogy of Fallot is having a hypercyanotic episode ('tet' spell). Which three nursing interventions are appropriate for the nurse to implement for this infant?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is C

Explanation

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