An infant with tetralogy of Fallot is having a hypercyanotic episode. Which of the following nursing interventions should the nurse implement? Select all that apply
1. Place the child in knee-chest position.
2. Draw blood for a serum hemoglobin.
3. Administer oxygen.
4. Administer morphine and propranolol intravenously as ordered.
5. Administer Benadryl as ordered.
1; 3; 4
Rationale:
1. When an infant with tetralogy of Fallot has a hypercyanotic episode, interventions should be geared toward decreasing the pulmonary vascular resistance. Therefore, the nurse would place the child in the knee-chest position (to decrease venous blood return from the lower extremities) and administer oxygen, morphine, and propranolol (to decrease the pulmonary vascular resistance).
2. The nurse would not draw blood until the episode had subsided, because unpleasant procedures are postponed.
3. When an infant with tetralogy of Fallot has a hypercyanotic episode, interventions should be geared toward decreasing the pulmonary vascular resistance. Therefore, the nurse would place the child in the knee-chest position (to decrease venous blood return from the lower extremities) and administer oxygen, morphine, and propranolol (to decrease the pulmonary vascular resistance).
4. When an infant with tetralogy of Fallot has a hypercyanotic episode, interventions should be geared toward decreasing the pulmonary vascular resistance. Therefore, the nurse would place the child in the knee-chest position (to decrease venous blood return from the lower extremities) and administer oxygen, morphine, and propranolol (to decrease the pulmonary vascular resistance).
5. Benadryl is not appropriate for this child.
You might also like to view...
A 66-year-old client arrives in the emergency department complaining of crushing chest pain following a large meal 4 hours before the onset. The pain has been recurring over the last several hours
The nurse assesses the client for presence of cardiac risk factors and finds none. The client asks the nurse if this means that there is no chance the client is having a cardiac event. How should the nurse respond? 1. "Even though you have no cardiac risk factors, it is still possible to have cardiac problems. We will want to completely evaluate you before we discharge you to home.". 2. "Since you have no cardiac risk factors, you probably have a respiratory illness, such as a cold, that is causing your chest pain. We will draw some blood, but will let you go home soon.". 3. "You have no cardiac risk factors, so the only reason you would be having chest pain now is related to how much you have eaten recently.". 4. "Since you have no cardiac risk factors, your chest pain is likely related to gallbladder disease, so there is no need to draw lab work.".
Which compensatory mechanism is spontaneously used by children diagnosed with tetralogy of Fallot to relieve hypoxic spells?
a. Lying on their left side b. Performing the Valsalva maneuver c. Squatting d. Hyperventilating
Patients with postpolio syndrome may be anxious and fearful because of health care practices and attitudes they encountered during the polio epidemic.
Answer the following statement true (T) or false (F)
When providing denture care,
A) providing privacy is not necessary. B) store plastic dentures in a cup of hot water. C) wearing gloves is not necessary. D) line the sink with paper towels.