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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Trimming toenails straight across is a general foot care recommendation but is not the most critical for preventing complications from an arterial ischemic leg ulcer.
Choice B reason: This is the correct choice. Daily inspection of the feet for skin breakdown is crucial for early detection and prevention of complications associated with arterial ischemic leg ulcers.
Choice C reason: Keeping legs elevated can help reduce swelling but is not as critical as daily foot inspection for preventing ulcer-related complications.
Choice D reason: Wearing shoes and socks is important for protecting the feet but does not directly prevent complications from an arterial ischemic leg ulcer.
Correct Answer is A
Explanation
Choice A reason: Allowing parents to hold their infant is a compassionate act that acknowledges their need for closure and can help them begin the grieving process.
Choice B reason: Interviewing parents to determine the cause of the incident is not considered supportive care; it may be part of an investigation but does not provide comfort.
Choice C reason: Providing mementos can be a cherished way for parents to remember their infant and can offer some solace during a difficult time.
Choice D reason: Advising parents about the necessity of an autopsy is not supportive care; it is a medical decision that should be discussed with sensitivity to the parents' feelings and needs. Autopsies can be important for understanding SIDS and preventing future occurrences.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.
