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 B
Explanation
Rationale
A. This role oversees the neurology unit but may not be directly involved in ICU care coordination, which requires a focus on acute management and transition to rehabilitation.
B. Nurse case managers are skilled in coordinating care for patients with complex conditions, ensuring continuity of care, and facilitating communication among healthcare providers and the client's family.
C. While an NP may be involved in direct patient care, their role is more focused on clinical management rather than comprehensive care coordination across different disciplines.
D. This role deals with patient safety and risk reduction but is not primarily responsible for coordinating care for a specific patient's acute medical needs and rehabilitation planning.
Correct Answer is C
Explanation
Rationale
A. Both baked potato with skin and raw carrots are high-fiber foods. The skin of the potato and raw carrots contain significant amounts of fiber, which can aggravate symptoms of ulcerative colitis.
B. Whole-grain cereals are high in fiber, which is not suitable for a low-fiber diet recommended for ulcerative colitis.
C. Roasted turkey is a lean protein source and generally suitable for a low-fiber diet. Canned vegetables can vary in fiber content; however, they are typically lower in fiber compared to fresh vegetables. The nurse should verify the specific type of canned vegetables to ensure they are low in fiber.
D. Fresh strawberries are high in fiber and should be avoided on a low-fiber diet.
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