Nokea
An infant with an unrepaired tetralogy of Fallot defect is becoming extremely cyanotic during a routine blood draw. Which interventions should the nurse implement? Place in order from the highest-priority intervention to the lowest-priority intervention. Provide the answer using lowercase letters separated by commas (e.g., a, b, c, d).
- A. Administer 100% oxygen by blow-by.
- B. Place the infant in knee-chest position.
- C. Remain calm.
- D. Give morphine subcutaneously or by an existing intravenous line.
Correct Answer: B
Rationale: Highest-priority intervention: Place the infant in the knee-chest position. This position can help increase systemic vascular resistance and reduce the shunting of blood from right to left in tetralogy of Fallot, temporarily improving oxygenation.
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24 hours after undergoing kidney transplantation, a client develops a hyperacute rejection. To correct this problem, the nurse should prepare the client for:
- A. Removal of the transplanted kidney
- B. High-dose IV cyclosporine (Sandimmune) therapy
- C. Bone marrow transplant
- D. Intra-abdominal instillation of methylprednisolone sodium succinate (Solu-Medrol)
Correct Answer: A
Rationale: Hyperacute rejection occurs immediately after transplantation, within minutes to up to 24 hours. It is a rapid and severe rejection reaction that is usually irreversible. It occurs due to pre-existing antibodies against the donor organ. In hyperacute rejection, the transplanted kidney must be removed to prevent further complications and ensure the safety of the patient. Treatment with immunosuppressive medications like cyclosporine or corticosteroids is not effective in this situation. Bone marrow transplant is not indicated in the treatment of hyperacute rejection.
The child begins to understand right and left by age of
- A. 3 yr
- B. 4 yr
- C. 5 yr
- D. 6 yr
Correct Answer: C
Rationale: Understanding right and left typically develops around age 5.
A one-month-old patient, who has developmental dysplasia of the hip, is placed in a hip spica cast. The patient's mother expresses the desire to continue breastfeeding. What is the pediatric nurse's best response?
- A. After breastfeeding, hold your baby upright for 45 minutes.
- B. Due to the weight of the cast, breastfeeding is not encouraged. I recommend that you bottle-feed.
- C. Breastfeeding can continue without significant changes; ensure proper positioning to accommodate the cast.
- D. none of the above.
Correct Answer: C
Rationale: Breastfeeding can continue even with a hip spica cast, but proper positioning is essential to ensure comfort for both the infant and the mother.
Mr. Aurelio diagnosed with heart failure, was prescribed with a 2 gm sodium diet. which of the following foods would nurse Norma instruct him to restrict?
- A. whole wheat bread
- B. canned tomato juice
- C. beef tenderloin strips
- D. apples
Correct Answer: B
Rationale: Canned tomato juice is often high in sodium content due to added salt during processing. Since Mr. Aurelio has been prescribed a 2 gm sodium diet, the nurse would instruct him to restrict foods high in sodium content, such as canned tomato juice. Whole wheat bread and apples are generally low in sodium, and beef tenderloin strips can be chosen in lean cuts and prepared without high sodium additives, making them more suitable for Mr. Aurelio's dietary restrictions.
A child 2 years 6 months of age has arranged a play date with a neighbor's child aged 2 years 9 months. During the play date, which behavior is most typical for children of this age?
- A. Share and trade toys while playing.
- B. Play with one another with little or no conflict.
- C. Engage in parallel play (playing alongside but not directly with one another).
- D. Play with only one or two items, ignoring most of the other toys.
Correct Answer: C
Rationale: Toddlers typically engage in parallel play rather than cooperative play.