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The nurse is feeding a 3-month-old client with tetralogy of Fallot. During the feeding, the client becomes cyanotic and has difficulty breathing. Which action should the nurse take first?
- A. Administer oxygen via face mask to the client
- B. Administer subcutaneous morphine to the client
- C. Obtain the client's pulse oximetry reading
- D. Place the client in the knee-chest position
Correct Answer: D
Rationale: The knee-chest position increases systemic vascular resistance and reduces right-to-left shunting in tetralogy of Fallot, immediately improving oxygenation during a tet spell.
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An adult is receiving nasal oxygen at 6 L/min. The client asks the nurse why the oxygen is humidified. What should the nurse include when responding to the client?
- A. Humidifying oxygen helps to prevent fire.
- B. Humidity increases the concentration of oxygen.
- C. Humidity helps to keep the nasal passages from drying out.
- D. Humidity reduces the growth of organisms in the tubing.
Correct Answer: C
Rationale: Humidification prevents nasal mucosal drying and discomfort at higher oxygen flow rates like 6 L/min, not fire prevention, concentration increase, or bacterial reduction.
A 6-year old is admitted with a diagnosis of childhood autism. Which behavior is most typical of the child with autism?
- A. A willingness to talk to strangers
- B. A disinterest in inanimate objects
- C. Engaging in ritualistic behavior
- D. A dislike of music
Correct Answer: C
Rationale: Children with autism often engage in ritualistic or repetitive behaviors, such as specific routines or movements, as a hallmark of the condition. Choice A is incorrect because children with autism typically have social communication difficulties and are less likely to engage with strangers. Choice B is incorrect as they may show intense interest in specific inanimate objects. Choice D is incorrect as music preference varies and is not a defining characteristic.
The nurse is assigning client care tasks to unlicensed assistive personnel. Which statement by the nurse is appropriate?
- A. I need you to take vital signs on all clients in rooms 1 through 10 this morning
- B. Mrs. Jones fell out of bed during the night while walking to the commode. Please monitor her closely.
- C. Please ensure that Mr. Garcia in room 8 ambulates several times.
- D. Please take Mr. Wu's vital signs in 10 minutes and let me know if his systolic blood pressure is <100.
Correct Answer: A
Rationale: Assigning vital signs for multiple clients is clear, specific, and within the UAP's scope of practice, ensuring safe delegation.
The nurse is caring for a hospitalized 6-month-old client. Which of the following interventions should the nurse implement to provide developmentally appropriate care for this client? Select all that apply.
- A. Adhere to the child's home routine when possible during hospitalization
- B. Encourage parents to bring the child's favorite toy from home
- C. Have the parents step out of the room during procedures
- D. Promote a quiet sleep environment with reduced stimuli
- E. Provide a parent's shirt for the child to hold during procedures
Correct Answer: A,B,D,E
Rationale: Following the home routine (A), providing familiar toys (B), ensuring a quiet sleep environment (D), and offering a parent's shirt (E) promote comfort and security for a 6-month-old.
The nurse is teaching parents about the treatment plan for a 2 weeks-old infant with Tetralogy of Fallot. While awaiting future surgery, the nurse instructs the parents to immediately report
- A. Loss of consciousness
- B. Feeding problems
- C. Poor weight gain
- D. Fatigue with crying
Correct Answer: A
Rationale: Loss of consciousness. This indicates anoxia, which may lead to death, requiring immediate reporting.