Following admission for a cardiac catheterization, the nurse is providing discharge teaching to the parents of a 2-year-old toddler with Tetralogy of Fallot. Which instruction should the nurse give the parents if their child becomes pale, cool, and lethargic?

Encourage oral electrolyte solution intake.

Contact their healthcare provider immediately.

Provide a quiet time by holding or rocking the toddler.

Assist the child to a recumbent position.

Answer and Explanation

The Correct Answer is B

Choice A reason: Electrolyte solutions address dehydration but are inappropriate for pale, cool, lethargic symptoms in Tetralogy of Fallot (TOF), indicating a hypercyanotic spell from right-to-left shunting. Urgent medical intervention restores oxygenation, making this inadequate compared to addressing the critical hypoxic episode requiring provider attention.

Choice B reason: Pale, cool, lethargy in TOF signals a hypercyanotic spell, where pulmonary stenosis increases right-to-left shunting, causing cyanosis and hypoxia. Contacting the provider ensures rapid interventions (e.g., oxygen, beta-blockers), preventing cerebral hypoxia or cardiac arrest, addressing the urgent pathophysiological crisis effectively.

Choice C reason: Quiet time by holding or rocking may calm the toddler but does not treat hypoxic spells in TOF, where pale, cool symptoms indicate shunting and hypoxia. Delaying medical intervention risks severe hypoxia, making this less critical than contacting the provider for urgent management.

Choice D reason: A recumbent position worsens TOF’s hypercyanotic spell, increasing venous return and shunting, exacerbating hypoxia. Knee-chest positioning reduces shunting. Contacting the provider is urgent to address pale, cool, lethargic symptoms, ensuring interventions to restore oxygenation, making this position contraindicated.

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Correct Answer is A

Explanation

Choice A reason: Starting the collection time after emptying the bag ensures an accurate 24-hour urine sample, critical for diagnostic tests like creatinine clearance. This defines the collection period, per laboratory and diagnostic specimen collection protocols in nursing practice.

Choice B reason: Catheter care prevents infection but is not the most critical step for initiating a 24-hour collection. Starting the collection time ensures accurate timing, essential for valid results, per urinary specimen collection and infection control standards in nursing.

Choice C reason: Clamping the catheter is inappropriate, as it disrupts continuous urine flow, skewing the 24-hour collection. Starting the collection time ensures accurate sampling, critical for diagnostic accuracy, per urinary catheter management and laboratory protocols in nursing practice.

Choice D reason: Labeling the container is important but secondary to starting the collection time, which defines the 24-hour period for accurate results. Timing ensures valid diagnostic data, per specimen collection and laboratory standards in nursing practice for urine collections.

A. Looking at the client from the side, observe the size and shape of the chest wall. B. Place the palm of the hand on the chest wall to feel vibrations while the client speaks. C. Use a stethoscope to listen to and compare breath sounds anteriorly and posteriorly. D. Use the fingertips to compress tissue over the lungs for evidence of a crackling sensation.

Correct Answer is B

Explanation

Choice A reason: Observing chest wall shape assesses for abnormalities like barrel chest, not tactile fremitus. Fremitus involves feeling vocal vibrations, increased in pneumonia due to consolidated lung tissue. Visual inspection does not evaluate vibration transmission, making it irrelevant for assessing fremitus in suspected pneumonia.

Choice B reason: Tactile fremitus is assessed by placing the palm on the chest while the client speaks, feeling vibrations through consolidated lung tissue in pneumonia. Fluid-filled alveoli enhance sound transmission, increasing fremitus. This directly evaluates lung pathology, confirming consolidation, critical for diagnosing pneumonia’s extent and severity.

Choice C reason: Using a stethoscope assesses breathing sounds like crackles, not tactile fremitus, which requires palpation of vocal vibrations. While breath sounds aid pneumonia diagnosis, fremitus specifically evaluates consolidation via vibration, making stethoscope use incorrect for this physical assessment technique focused on lung tissue density.

Choice D reason: Compressing tissue for crackling assesses crepitus or subcutaneous emphysema, not fremitus. In pneumonia, fremitus increases due to consolidation, not tissue compression. This method is irrelevant, as fremitus relies on vocal vibration transmission through palpation, making it inappropriate for assessing pneumonia-related lung changes.

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Following admission for a cardiac catheterization, the nurse is providing discharge teaching to the parents of a 2-year-old toddler with Tetralogy of Fallot. Which instruction should the nurse give the parents if their child becomes pale, cool, and lethargic?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

In assessing tactile fremitus in the client with suspected pneumonia, the nurse should perform which action?

Correct Answer is B

Explanation

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