The nurse would teach the mother of a boy with Tetralogy of Fallot that if the child suddenly becomes cyanotic and dyspneic, the mother should:

Place him in knee-chest position

Have him lie prone, being sure he can breathe easily

Have him lie supine with the head turned to one side

Place him in semi-fowler's position in an infant seat

Answer and Explanation

The Correct Answer is A

A. The knee-chest position increases systemic vascular resistance, which helps to divert more blood to the pulmonary circulation, improving oxygenation in a child experiencing a "tet spell" or hypercyanotic episode.

B. The prone position does not help in relieving cyanosis and dyspnea in Tetralogy of Fallot.

C. The supine position with the head turned does not assist in improving oxygenation during a cyanotic episode.

D. The semi-Fowler's position may aid breathing but is less effective than the knee-chest position in managing cyanotic spells.

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Correct Answer is B

Explanation

A. Cromolyn sodium is a preventive medication and should be taken regularly as prescribed, not at the first sign of breathing difficulty.

B. Avoiding triggers that cause an asthma attack is crucial in asthma management and helps in preventing exacerbations.

C. Exercise can be managed in asthma with appropriate medication; it is not necessary to stop activities like basketball. Swimming may be less likely to trigger asthma symptoms but is not a blanket solution.

D. The peak expiratory flow meter should be used regularly, often daily, to monitor asthma control, not just once per week.

A. BP 90/52 mm Hg, heart rate 120/min, respirations 28/min, and axillary temperature of 37.3°C (99.1°F) B. BP 79/40 mm Hg, heart rate 135/min, respirations 32/min, and oral temperature of 38° C (100.4" F) C. BP 85/50 mm Hg, heart rate 95/min, respirations 26/min, and axillary temperature of 36.7° C (98.1° F) D. BP 88/45 mm Hg, heart rate 113/min, respirations 28/min, and oral temperature 37.6" C (99.7" F)

Correct Answer is B

Explanation

A. These vital signs are generally within expected ranges for a 2-year-old child.

B. A blood pressure of 79/40 mm Hg is low for a 2-year-old, and the elevated heart rate of 135/min and increased respirations suggest that the child may be experiencing significant distress or volume depletion, requiring immediate attention.

C. These vital signs are within normal limits for a 2-year-old child.

D. Although the blood pressure is on the lower end of normal and heart rate is slightly elevated, these findings are less concerning than option B.

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The nurse would teach the mother of a boy with Tetralogy of Fallot that if the child suddenly becomes cyanotic and dyspneic, the mother should:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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