Nokea
The nurse is reinforcing discharge teaching for the parents of an infant with tetralogy of Fallot. Which of the following actions should the nurse include to reduce the incidence of hypercyanotic spells? Select all that apply.
- A. Dress the infant in warm clothing and blankets
- B. Encourage smaller, frequent feedings
- C. Intervene quickly to prevent the infant from crying excessively
- D. Promote a quiet period on waking in the morning
- E. Turn the infant frequently during sleep
Correct Answer: B,C,D
Rationale: Smaller feedings, preventing crying, and quiet periods reduce oxygen demand, minimizing hypercyanotic spells. Warm clothing and frequent turning do not directly prevent spells.
You may also like to solve these questions
A woman comes into the labor suite stating that her water has broken and she is in labor. Which symptoms point to the possible presence of placenta previa?
- A. Sudden knife-like pain in the lower abdomen accompanied by profuse vaginal bleeding
- B. Dark red vaginal discharge that started after she saw the physician this morning
- C. Bright red painless vaginal bleeding
- D. A tender rigid uterine wall and abdomen with no vaginal bleeding evident
Correct Answer: C
Rationale: Placenta previa typically presents with bright red, painless vaginal bleeding due to the placenta covering the cervix, distinguishing it from abruptio placentae or other conditions.
The nurse in the outpatient clinic is talking with a client who was diagnosed with hypertension 6 months ago. The client’s current blood pressure is 170/94 mm Hg. Which of the following questions would be most important for the nurse to ask?
- A. Are you feeling overwhelmed at home or work?
- B. Can you describe your daily eating habits to me?
- C. Do you smoke cigarettes or use tobacco products?
- D. How often do you take your antihypertensive medications?
Correct Answer: D
Rationale: Medication adherence is the most critical factor to assess in uncontrolled hypertension (170/94 mm Hg), as non-compliance is a common cause. Stress, diet, and smoking are secondary.
Which nursing intervention is most critical during the administration of Acyclovir (Zovirax)?
- A. Limit the client's activity.
- B. Encourage a high-carbohydrate diet.
- C. Utilize an incentive spirometer to improve respiratory function.
- D. Encourage fluids.
Correct Answer: D
Rationale: Acyclovir can cause renal toxicity; encouraging fluids promotes renal perfusion and reduces risk of crystal formation in the kidneys.
The nurse is preparing the sterile field and supplies for a wet-to-damp dressing change. Which of the following actions by the nurse would require follow-up?
- A. Drop sterile gauze on the sterile field from 6 inches (15cm ) above
- B. Keeps the sterile field and sterile gloved hands within view at all times
- C. Places sterile gauze 2 inches (5 cm) inside the outer edge of the sterile drape
- D. Pours sterile saline solution from a recapped bottle opened 30 hours ago
Correct Answer: D
Rationale: Using saline from a bottle opened 30 hours ago risks contamination, as sterile solutions are typically discarded after 24 hours. Keeping the field in view and placing gauze appropriately maintain sterility.
The nurse is caring for a client with Grave's disease. Which finding would indicate a complication of the client's disease?
- A. Extreme fatigue
- B. Increased heart rate
- C. Shortness of breath
- D. Urinary frequency
Correct Answer: C
Rationale: Shortness of breath may indicate thyroid storm, a life-threatening complication of Grave's disease. Fatigue and increased heart rate are common symptoms, and urinary frequency is unrelated.