Patient Data
Review H and P, nurse's notes, and laboratory results.
Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress,
The Correct Answer is []
Potential condition: Polycythemia
Actions to take
Have the parents increase the child's caloric intake: Polycythemia in children with tetralogy of Fallot can be managed by ensuring adequate hydration and nutrition. Increasing caloric intake helps support growth and development and can prevent excessive erythrocytosis.
Take the child's vital signs: Regular monitoring of vital signs, including heart rate, respiratory rate, blood pressure, and temperature, is essential to assess the child's cardiovascular status and response to treatment.
Parameters to monitor
Oxygen saturation: Monitoring oxygen saturation helps assess the adequacy of pulmonary blood flow and oxygenation in a child with tetralogy of Fallot and polycythemia.
Weight: Monitoring weight is crucial to assess growth and nutritional status. Children with tetralogy of Fallot may have poor weight gain due to increased metabolic demands and potential feeding difficulties.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Rationale
A. Wearing a face mask is a standard precaution to protect against airborne or droplet transmission of pathogens. However, MRSA is primarily transmitted through direct contact with infected wounds or contaminated surfaces rather than through the air.
B. Contact precautions are essential for preventing the spread of MRSA. These precautions include wearing gloves and gowns when in direct contact with the client or potentially contaminated surfaces. However, this is not of immediate concern.
C. Monitoring the white blood cell count (WBC) is crucial in assessing for signs of infection, including wound infections. An increase in WBC count can indicate systemic infection or local wound infection, which might be related to MRSA. Early detection and prompt reporting allow for timely intervention, such as initiating appropriate antibiotic therapy or further wound assessment.
D. This is because maintaining a clean environment around the wound is crucial to prevent infection
Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"A"}}
Explanation
Correct choices are;
A.I should have taken an extra dose of fluticasone-salmeterol -No Understanding
Explanation: Fluticasone/salmeterol is a long-acting inhaler used for maintenance therapy in asthma. It is not meant to be used as a rescue medication for acute symptoms or exacerbations. Therefore, taking an extra dose in response to symptoms would not be appropriate.
B. I should have taken some allergy medications before going on the hike -Understanding
Explanation: Allergy medications, such as antihistamines or nasal sprays, can help reduce allergic triggers that can exacerbate asthma symptoms. Taking these medications before exposure to known triggers (like allergens during a hike) can help prevent an asthma exacerbation.
C. I have been very stressed out lately and should work on stress management -Understanding
Explanation: Stress is a known trigger for asthma exacerbations. Managing stress through techniques such as relaxation exercises, mindfulness, or therapy can help reduce the likelihood of triggering asthma symptoms.
D. I should have eaten a snack halfway through the hike - No Understanding
Explanation: While maintaining good nutrition and hydration is important for overall health, eating a snack would not necessarily prevent an asthma exacerbation unless the snack contained medications or substances that specifically manage asthma symptoms.
E. My friend smoked cigarettes during the hike - Understanding
Explanation: Secondhand smoke is a common trigger for asthma exacerbations. Being exposed to cigarette smoke can irritate the airways and worsen asthma symptoms.
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