A family brought their 3-week-old infant to the hospital by ambulance after having a seizure at home.
The baby received phenytoin in the ambulance and arrived at the hospital on 1 L/minute oxygen with a 22-gauge peripheral IV line in the left saphenous vein.
Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client’s progress.
Review H and P, nurse’s notes, flow sheet, and orders.
Call for a chest x-ray.
Hypocalcemia.
Monitor respiratory rate.
The Correct Answer is C
Choice A rationale
Reviewing the history and physical (H&P), nurse’s notes, flow sheet, and orders is a standard part of nursing care for any patient. However, in the case of a 3-week-old infant who has had a seizure, this action alone would not directly address the condition the infant is most likely experiencing.
Choice B rationale
While calling for a chest x-ray could be part of the diagnostic process for certain conditions, it is not typically the first action taken in response to a seizure in an infant.
Choice C rationale
Hypocalcemia, or low calcium levels in the blood, can cause seizures in infants. Phenytoin, the medication given to the baby in the ambulance, is used to control seizures. Therefore, hypocalcemia could be the condition the infant is experiencing.
Choice D rationale
Monitoring the respiratory rate is an important part of assessing any patient’s condition, especially an infant who has had a seizure. However, it does not specify the condition the infant is most likely experiencing.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["1.8"]
Explanation
The client weighs 132 pounds. To convert pounds to kilograms, divide the weight in pounds by
2.2. So, the client’s weight in kilograms is: Step 1: 132 pounds ÷ 2.2 = 60 kg The prescription for dantrolene is 1.5 mg/kg. To find out how many milligrams the client should receive, multiply the client’s weight in kilograms by the dosage in mg/kg: Step 2: 60 kg × 1.5 mg/kg = 90 mg The vial is reconstituted to yield a concentration of 50 mg/mL. To find out how many mL the nurse should administer, divide the total dosage in milligrams by the concentration in mg/mL: Step 3: 90 mg ÷ 50 mg/mL = 1.8 mL So, the nurse should administer 1.8 mL of dantrolene.
Correct Answer is A
Explanation
Choice A rationale
The unlicensed assistive personnel (UAP) is providing care to a client with influenza, a respiratory illness that can be transmitted through droplets when the client coughs or sneezes. Therefore, it is crucial for the UAP to wear a face mask while in close contact with the client to prevent the transmission of the virus. This is in line with the standard precautions for infection control, which recommend the use of personal protective equipment (PPE) such as gloves, gowns, and masks when providing care to clients with infectious diseases.
Choice B rationale
Reassigning the UAP to another client and assuming full care of the client is not the most appropriate action in this situation. While it is the nurse’s responsibility to ensure that the UAP is competent and understands the care needs of the client, it is not necessary to reassign the UAP unless there are specific concerns about their ability to provide safe and effective care.
Choice C rationale
While it is important for the UAP to alert the nurse of any changes in the client’s respiratory status, this is not the most immediate action that the nurse should take in this situation. The priority is to ensure that the UAP is wearing appropriate PPE to prevent the transmission of influenza.
Choice D rationale
A fitted respirator mask is typically used when caring for clients with airborne diseases, such as tuberculosis. Influenza is primarily spread through droplets, so a regular face mask is usually sufficient for protection.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.