A child diagnosed with strep throat 3 days ago enters the clinic crying hysterically. The parent tells the practical nurse (PN) that the child screams in pain even with a light touch. The child is short of breath and anxious. Which manifestations warrant immediate intervention by the
PN?

Slightly raised rash with ragged edges.

Red, hot, and swollen joints.

Heart rate 110 beats/minute.

Pulse oximetry of 88% O2 saturation.

Answer and Explanation

Correct Answer : B,D

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Correct Answer is ["A","B","D"]

Explanation

A. Measure head circumference daily. - Monitoring head circumference is crucial to detect changes that might indicate increased intracranial pressure after the shunt placement.
B. Document strict intake and output. - Monitoring fluid intake and output helps assess the infant's hydration status and shunt functionality.
C. Irrigate shunt and pump valve every 12-hours. - Shunt irrigation should be performed by specialized healthcare professionals, not typically by a practical nurse.
D. Monitor body temperature every 4 hours. - Postoperative monitoring includes assessing for signs of infection or systemic changes, which might be indicated by changes in body temperature.
E. Place in Trendelenburg position. - The Trendelenburg position is not typically recommended post-ventriculoperitoneal shunt placement and should be avoided unless specifically prescribed by the healthcare provider.

A. Wrap him with a warm blanket. B. Give prescribed analgesic. C. Obtain blood glucose level. D. Burp the infant every two hours.

Correct Answer is B

Explanation

A. Wrapping the infant with a warm blanket might provide comfort but may not directly address the signs of discomfort or pain.
B. Giving the prescribed analgesic is essential to alleviate the infant's discomfort or pain following a surgical procedure like pylorotomy.
C. Obtaining blood glucose level might be necessary in certain situations but does not directly address the observed signs of discomfort and pain in the infant.
D. Burping the infant every two hours may relieve gas but does not address the symptoms of restlessness, grimacing, and drawing knees to the chest, which are indicative of pain or discomfort post-surgery.

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A child diagnosed with strep throat 3 days ago enters the clinic crying hysterically. The parent tells the practical nurse (PN) that the child screams in pain even with a light touch. The child is short of breath and anxious. Which manifestations warrant immediate intervention by the PN?

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Naxlex Comprehensive Predictor Exams

A 2-day-old infant with hydrocephalus returns from surgery following placement of a ventriculoperitoneal shunt. Which nursing intervention(s) should the practical nurse (PN) implement during postoperative care? (Select all that apply.)

Correct Answer is ["A","B","D"]

Explanation

The practical nurse (PN) is caring for a 3-month-old male infant two days after a pylorotomy and notices that the infant is restless, grimacing, and drawing his knees to his chest. What action should the PN implement?

Correct Answer is B

Explanation

A child diagnosed with strep throat 3 days ago enters the clinic crying hysterically. The parent tells the practical nurse (PN) that the child screams in pain even with a light touch. The child is short of breath and anxious. Which manifestations warrant immediate intervention by the PN?

The practical nurse (PN) is assigning care for a group of clients on the urology medical unit. Which client care interventions should the PN assign to the unlicensed assistive personnel (UAP)? (Select all that apply.)

The practical nurse (PN) palpates a client's radial pulse and notes that the pulse disappears when light pressure is applied. How should the PN document this finding?

During the first trimester of pregnancy, a client who was treated for genital herpes with acyclovir prior to this pregnancy tells the practical nurse (PN) that she is experiencing an episode of genital herpes. Which nursing intervention has the highest priority?

A highly successful businessman presents to the community mental health center complaining of sleeplessness and anxiety over his financial status. Which action should the practical nurse (PN) take to assist this client in diminishing his anxiety?

The practical nurse (PN) assists a client to a supine position. What should the PN use to prevent external rotation of the client's hips?

The practical nurse (PN) is explaining the use of an incentive spirometer to a postoperative client. The client asks the PN to administer an analgesic before using the spirometer. How should the PN respond?

The practical nurse (PN) observes two unlicensed assistive personnel (UAP) turning an older client who had a hip arthroplasty with prosthesis placement four hours ago. Which observation by the PN indicates that the UAPS needs additional information about the turning procedure?

A child diagnosed with strep throat 3 days ago enters the clinic crying hysterically. The parent tells the practical nurse (PN) that the child screams in pain even with a light touch. The child is short of breath and anxious. Which manifestations warrant immediate intervention by the
PN?