A full-term, 24-hour-old infant in the nursery regurgitates and suddenly turns cyanotic. Which immediate intervention should the practical nurse (PN) implement?

Turn the infant onto the right side.

Suction the oral and nasal passages.

Give oxygen by positive pressure.

Stimulate the infant to cry.

Answer and Explanation

The Correct Answer is B

In this scenario, the sudden regurgitation and cyanosis in a 24-hour-old infant indicate a potential airway obstruction or compromise. The immediate priority is to clear the airway and ensure adequate ventilation.

Suctioning the oral and nasal passages helps remove any potential obstruction or mucus that may be causing the cyanosis. This intervention aims to restore normal airﬂow and prevent further respiratory distress in the infant.

Let's brieﬂy evaluate the other options:

a) Turn the infant onto the right side.

Positioning the infant onto the right side does not directly address the potential airway obstruction or cyanosis. While positioning may have some benefit in certain situations, such as facilitating drainage, it is not the most appropriate immediate intervention in this case.

c) Give oxygen by positive pressure.

Administering oxygen by positive pressure may be necessary if the infant's oxygen saturation remains low after suctioning and clearing the airway. However, suctioning should be the initial intervention to address any potential airway obstruction or mucus before considering oxygen administration.

d) Stimulate the infant to cry.

Stimulating the infant to cry is not the appropriate intervention in this case. It does not directly address the potential airway obstruction or cyanosis. Crying requires a patent airway, and if the infant is already cyanotic, it suggests an obstruction or inadequate ventilation. Therefore, suctioning and clearing the airway take precedence over stimulating the infant to cry.

In summary, when a full-term, 24-hour-old infant in the nursery regurgitates and suddenly turns cyanotic, the practical nurse should immediately suction the oral and nasal passages to clear any potential airway obstruction or mucus. This intervention aims to restore normal airﬂow and ensure adequate ventilation for the infant.

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Correct Answer is D

Explanation

Acne is a common skin condition that often requires specialized treatment. While general skincare practices can help maintain healthy skin, the most appropriate recommendation for a 16-year-old client seeking treatment for acne is to refer them to a dermatologist.

Acne can have various underlying causes, and eﬀective treatment often involves a tailored approach based on the individual's specific condition. Dermatologists are medical professionals specializing in skin health and are best equipped to assess and provide appropriate treatment options for acne.

Let's brieﬂy evaluate the other options:

a) Wash the hair and skin daily with mild soap and warm water.
While maintaining good hygiene is important for overall skin health, washing the hair and skin alone may not be sufficient to address acne. Acne is a multifactorial condition that requires more comprehensive treatment beyond basic hygiene practices.

b) Omit chocolate, carbonated drinks, and fried foods from the diet.
While diet can play a role in overall skin health, there is limited scientific evidence linking specific foods to the development or worsening of acne. Restricting specific foods may not be the most eﬀective or necessary approach for treating acne. Additionally, dietary changes alone may not address the underlying causes of acne.

c) Express blackheads and follow with an exfoliating scrub.
Squeezing or expressing blackheads can potentially worsen acne and lead to skin damage or infection. It is generally not recommended to atempt self-extraction of blackheads or use aggressive exfoliating scrubs without professional guidance.

In summary, when a 16-year-old client seeks advice for acne, the most appropriate recommendation for the practical nurse (PN) is to refer the client to a dermatologist for prescribed long-term therapy.
Dermatologists have the expertise to evaluate the individual's specific condition and provide appropriate treatment options tailored to their needs.

A. Monitoring vital signs and neurological status frequently. B. Maintaining strict bed rest to minimize cerebral blood flow. C. Administering anticoagulant medications as prescribeD. D. Assisting the client with active range of motion exercises.

Correct Answer is A

Explanation

Choice A reason: Monitoring vital signs and neurological status frequently is the priority intervention for the client because it can detect changes in the client's condition, such as increased intracranial pressure, bleeding, or infection, that require immediate action.

Choice B reason: Maintaining strict bed rest to minimize cerebral blood flow is not the priority intervention for the client because it can increase the risk of complications such as deep vein thrombosis, pulmonary embolism, or pneumoniA. The client should be positioned with the head of the bed elevated at 30 degrees to reduce intracranial pressure and facilitate drainagE.

Choice C reason: Administering anticoagulant medications as prescribed is not the priority intervention for the client because it can worsen the bleeding and increase the risk of hemorrhagic transformation. Anticoagulants are contraindicated for clients who have hemorrhagic stroke, which is caused by rupture of a blood vessel in the brain.

Choice D reason: Assisting the client with active range of motion exercises is not the priority intervention for the client because it can cause fatigue, pain, or injury to the affected limbs. The client should be assisted with passive range of motion exercises to prevent contractures and maintain joint mobility.

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A full-term, 24-hour-old infant in the nursery regurgitates and suddenly turns cyanotic. Which immediate intervention should the practical nurse (PN) implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A 16-year-old client is asking the practical nurse (PN) what can be done about acne. Which recommendation should the PN provide?

Correct Answer is D

Explanation

A nurse is caring for a client who has experienced a hemorrhagic strokE. Which intervention should the nurse prioritize when providing care to the client?

Correct Answer is A

Explanation

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