Hypercyanotic spells, also known as “tet” spells, are frequently observed in tetralogy of Fallot (TOF) and other heart defects that reduce pulmonary blood flow. These spells occur when oxygen demands rise, such as during stress, crying, or feeding, leading to infundibular spasm. This spasm augments right-to-left shunting of blood away from the pulmonary circulation, resulting in hypoxia. During a hypercyanotic episode, the nurse should implement interventions aimed at increasing oxygenation and pulmonary blood flow, starting with the fastest and least invasive action. This typically involves placing the infant in the knees-to-chest position to increase systemic vascular resistance. Additionally, calming the infant by providing a dim, quiet environment, swaddling, and encouraging caregiver participation can help decrease oxygen demand. Finally, administering oxygen is essential to improve oxygenation.

Intussusception involves the telescoping of a proximal portion of the intestine into a distal portion, which can lead to decreased circulation, necrosis, and bowel perforation. Manifestations of bowel perforation include abdominal rigidity, irritability, and early signs of shock. In the event of bowel perforation, IV fluids should be promptly administered to replace intravascular fluid loss and improve perfusion. Additionally, IV antibiotics, gastric decompression, and oxygen therapy are initiated until the client undergoes surgery to decontaminate the peritoneum and repair the bowel.

Acid-base imbalances are classified as respiratory or metabolic and occur due to shifts in acidic (e.g., carbon dioxide [CO2]) and alkaline (e.g., bicarbonate [HCO3−]) compounds in the body. In arterial blood gas interpretation, a low pH indicates acidosis, while a high PaCO2 suggests a problem with gas exchange in the lungs or a respiratory issue. Respiratory acidosis occurs when there is a buildup of CO2 in the body, often seen in conditions such as chronic obstructive pulmonary disease (COPD), where airflow obstruction leads to inadequate carbon dioxide expulsion. Increasing the respiratory rate helps eliminate excess CO2 from the body, improving ventilation and correcting acidosis.

When assisting clients with activities of daily living (ADLs), it’s crucial for the nurse to consider any precautions or contraindications. In the case of diabetes mellitus, peripheral neuropathy can lead to decreased sensation in the feet. Consequently, soaking the feet in warm water poses a risk for burns or infection. Due to decreased sensation, the client may not be able to feel if the water is too hot, increasing the risk for burns. Prolonged moisture can also elevate the risk for infection, which is particularly concerning for clients with diabetes due to their delayed wound healing.

Sexually transmitted infections (STIs) (e.g., chlamydia, gonorrhea) are spread through bodily fluids and skin-to-skin contact during sexual activity. STI education focuses on transmission, prevention, treatment, and complications.

Effective teaching: 
Clients treated for STIs should tell recent sex partners so the partner can be tested. This improves awareness of STI exposure and prevents further STI transmission.
Many clients with STIs are asymptomatic. Some symptoms may not appear until days or years after infection.
Chlamydia is a bacterial infection caused by Chlamydia trachomatis that is treated with antibiotics (e.g., doxycycline, azithromycin).
If left untreated, chlamydia can lead to pelvic inflammatory disease (PID), which can cause a build-up of scar tissue, leading to infertility and ectopic pregnancy.

Potassium is essential for proper muscle function, nerve function, and several biochemical processes in the body. Several factors can lead to hypokalemia (low serum potassium). Common causes of hypokalemia include:
Excessive potassium loss from the gastrointestinal tract (e.g., vomiting, diarrhea), which is a major route of potassium excretion.
Renal losses through medications (e.g., loop diuretics) that promote potassium excretion.
Hormonal imbalances, such as hyperaldosteronism (e.g., Conn syndrome), which increases renal potassium excretion.

Pertussis, or whooping cough, is a highly contagious, acute bacterial respiratory infection that causes coryza (nasal congestion), sneezing, and paroxysmal coughing episodes with an inspiratory “whooping” sound, frequently followed by vomiting. Pertussis is spread by airborne droplets and requires droplet precautions. Although a private room is preferred, clients requiring droplet precautions with the same droplet illness (e.g., pertussis, influenza, rubella) can safely room together since the risk of reinfection is minimal compared to airborne illnesses.

Restraints can be physical (e.g., mittens, soft extremity) or chemical (e.g., sedatives) and are prescribed to promote safety when less restrictive measures fail (e.g., reorienting). A soft wrist restraint is a cuff placed around the wrist and secured to a non-movable part of the bed frame using a quick-release knot (slipknot) to immobilize the upper extremities. The nurse should avoid securing restraints to the side rails because the restraint will tighten if the rail is lowered.

Registered nurses (RNs) should only delegate tasks that satisfy the five rights of delegation and are within the delegatee’s scope of practice. Sitting at the bedside of an older adult client who is confused and at high risk for falls requires ensuring client safety and providing reorientation. This task does not require nursing judgment or critical decision-making, so it is appropriate to delegate to UAP, who are trained to support basic safety measures.

Nurses must ensure client confidentiality to reduce liability and preserve client dignity. This is done by only sharing relevant information with the appropriate parties, which includes healthcare team members who are directly involved in the client’s care, individuals authorized by the client, or when mandatory reporting is required. If a language barrier exists, the nurse should utilize a professional interpreter. Asking a family member to serve as an interpreter is inappropriate because sharing health information with the family without first obtaining consent violates confidentiality.