Pre-Test 1 and 2: Introduction to Special Questions Based on Official NCLEX-RN[®]
74. A nurse is performing health teaching with the parents of a 16-month-old child who has tetralogy of Fallot. Which steps should the nurse advise the parents to take to properly respond to a "tet spell"?
Select all that apply.
. Call EMS.
. Sit the child in a chair.
. Learn CPR.
. Administer aspirin.
. Ask the child to cough.
. Place child on the side with knees to chest.
Test-Taking Tip
The best sequence of steps is: CPR training → positioning → calling for help.
Content Area: Child Health, Cardiovascular; Integrated Process: Nursing Process, Implementation; Cognitive Level: Application; Client Need/Subneed: Physiological Integrity/Physiological Adaptation/Hemodynamics
Pre-Test 1 and 2: Introduction to Special Questions Based on Official NCLEX-RN[®]
. . .
Answer 1 is correct because, after taking action to treat the "tet spell," the parents should activate emergency medical services (EMS). Answer 2 is incorrect because the child should be placed on the side, not upright in a chair. Answer 3 is correct because, before the child might have a "tet spell," parents should first get trained in CPR, in order to be ready should their child need such intervention. Answer 4 is incorrect because nothing should be placed in the child's mouth during a "tet spell." Aspirin is not used to treat this condition; it is given for the treatment of heart attack. Answer 5 is incorrect because coughing will not reverse a "tet spell"; it is the treatment for supraventricular tachycardia. Answer 6 is correct because the parents' first response during a "tet spell" should be to place the child in the position that will increase systemic vascular resistance and prevent fainting.