A father asks why his child with tetralogy of Fallot seems to favor a squatting position. What is the nurse’s best response?

Correct Answer: A

Rationale: The correct answer is A) Squatting increases the return of venous blood back to the heart. In Tetralogy of Fallot, a congenital heart defect, there is decreased pulmonary blood flow leading to cyanosis. By squatting, the child instinctively increases systemic vascular resistance and reduces the right-to-left shunting of blood in the heart, thus improving oxygenation. This position assists in maintaining cardiac output and systemic perfusion by reducing the pressure gradient across the right ventricular outflow tract. Option B) Squatting decreases arterial blood flow away from the heart is incorrect as squatting actually helps in improving systemic blood flow. Option C) Squatting is a common resting position when a child is tachycardic is incorrect as squatting in this context is not related to tachycardia but rather a compensatory mechanism for the underlying heart defect. Option D) Squatting increases the workload of the heart is incorrect as squatting actually helps in reducing the workload on the heart by improving venous return and systemic perfusion. Understanding the rationale behind why children with Tetralogy of Fallot assume a squatting position is crucial for nurses caring for pediatric patients with cardiovascular disorders. It highlights the body's innate compensatory mechanisms and the importance of recognizing and supporting these strategies to optimize patient outcomes.

Correct Answer: A

Rationale: In this scenario, the correct intervention is option A) Reorient client to his room. Pontine myelinolysis is a serious neurological condition characterized by the destruction of the myelin sheath in the pons region of the brain. Symptoms include confusion, dysphagia, quadriplegia, and can be life-threatening. Reorienting the client to his room is the priority as confusion is a common symptom and the client may be disoriented due to the neurological damage. Option B) Place a patch on one eye is unrelated to the client's condition and would not address the neurological symptoms associated with pontine myelinolysis. Option C) Evaluate client's ability to swallow is important but not the most immediate concern in this situation. Option D) Perform range of motion exercises is not a priority when dealing with a neurological emergency like pontine myelinolysis. Educationally, understanding the priority interventions in neurological emergencies is crucial for nurses caring for pediatric patients with complex conditions. This question highlights the importance of quick thinking and prioritization in the face of a critical situation to provide optimal care and support to the patient.

Correct Answer: A

Rationale: In this pharmacology question, the correct answer is A) 0.6 ml. To calculate the correct dosage, the nurse first needs to determine the client's weight in kilograms (175 lbs ÷ 2.2 = 79.5 kg). Then, the nurse calculates the heparin dose by multiplying the weight in kg by the prescribed dose (80 units/kg x 79.5 kg = 6,360 units). Next, the nurse needs to determine how many ml of the 10,000 units/ml heparin vial to administer (6,360 units ÷ 10,000 units/ml = 0.636 ml). Rounding to the nearest tenth, the nurse should administer 0.6 ml. Option B) 0 is incorrect because the nurse should administer a dose of heparin based on the client's weight and the prescribed dosage. Option C) 6 is incorrect because it represents the total units of heparin required, not the volume in ml that should be administered. Option D) 1 is incorrect as it does not accurately reflect the calculated dose based on the client's weight and the concentration of the heparin vial. This question provides essential pharmacological calculations for pediatric nursing students. Understanding how to calculate medication dosages based on a client's weight and available concentrations is crucial for safe and effective pediatric patient care. This scenario also reinforces the importance of accurate dosage calculations to prevent medication errors and ensure optimal patient outcomes.

Correct Answer: B

Rationale: In this scenario, the correct answer is B) The xenograft is taken from nonhuman sources. Explanation: Xenografts are skin grafts taken from a different species, such as pig or cow, and used in burn patients to promote healing. Providing this information to a Jewish client is crucial for cultural sensitivity, as some Jewish individuals may have dietary restrictions or beliefs that impact their acceptance of treatments involving nonhuman sources. Why others are wrong: A) Grafting increases the risk for bacterial infections: While this is a potential risk associated with any type of grafting procedure, it is not specific to xenografts and is not the most pertinent information for preoperative education in this case. C) Grafts are later removed by a debriding procedure: This statement is inaccurate as xenografts are typically used as temporary coverings until the patient's own skin can be used for grafting, and they are not removed by debriding procedures. D) As the burn heals, the graft permanently attaches: This statement is incorrect as xenografts are temporary and eventually slough off as the patient's own skin regenerates underneath. Educational context: Understanding the source and nature of the graft is essential for the client's informed decision-making and compliance with the treatment plan. Providing culturally sensitive and accurate information ensures effective communication and fosters trust between the healthcare provider and the client.

Correct Answer: C

Rationale: In this scenario, the correct action for the nurse to implement is to measure the patient's pulse and blood pressure (Option C). This is crucial because the patient is experiencing symptoms of weakness and jitteriness, which could indicate hypoglycemia, a common complication in diabetes management. Checking the pulse and blood pressure can help assess the patient's hemodynamic status and provide valuable information about his overall condition. Option A (Checking his fingerstick glucose level) could also be important in this situation to confirm if the patient's symptoms are indeed related to hypoglycemia. However, measuring the pulse and blood pressure takes precedence as it provides immediate data on the patient's cardiovascular status, especially during a perioperative period. Options B (Assessing his skin temperature and moisture) and D (Documenting anxiety on the surgical checklist) are not the most appropriate actions to take in response to the patient's symptoms. While assessing skin temperature and moisture can provide some information about the patient's perfusion status, it may not directly address the immediate concern of weakness and jitteriness. Documenting anxiety, although important for holistic care, does not address the physiological symptoms the patient is experiencing and should not be the priority in this situation. From an educational perspective, this scenario highlights the importance of prioritizing nursing actions based on the patient's presenting symptoms and clinical context. Understanding the significance of assessing vital signs in a timely manner, especially in patients with comorbid conditions like diabetes, is crucial for providing safe and effective care. It also underscores the need for nurses to be adept at recognizing and managing potential complications in patients with chronic illnesses undergoing surgical procedures.