A mother brings her 3-week-old son to the clinic because he is vomiting "all the time." In performing a physical assessment, the nurse notes that the infant has poor skin turgor, has lost 20% of his birth weight, and has a small palpable oval-shaped mass in his abdomen. Which intervention should the nurse implement first?

Initiate a prescribed IV for parenteral fluid.

Feed the infant 3 ounces of Isomil.

Give the infant 5% dextrose in water orally.

Insert a nasogastric tube for feeding.

Answer and Explanation

The Correct Answer is A

The presenting symptoms of the infant, including persistent vomiting, poor skin turgor, significant weight loss, and a palpable abdominal mass, indicate a potential serious condition that requires immediate attention. These findings may suggest dehydration, malnutrition, and the presence of an abdominal mass that could be causing gastrointestinal obstruction or other underlying pathology.

Initiating a prescribed IV for parenteral fluid is the priority intervention to address the potential dehydration and fluid imbalance in the infant. This will help restore and maintain adequate hydration while further diagnostic evaluations and interventions are initiated.

Feeding the infant, giving 5% dextrose in water orally, or inserting a nasogastric tube for feeding should not be implemented as the first intervention in this case. It is important to stabilize the infant's fluid status before initiating oral feedings or other interventions to address the underlying cause of the symptoms.

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Correct Answer is C

Explanation

A) This option is unnecessary because droplet precautions do not require a particulate filter mask. Particulate filter masks are needed for airborne precautions. Sending the UAP for fitting delays care without providing additional safety benefits for droplet precautions.

B) While a standard face mask is appropriate for droplet precautions, the part about getting fitted for a filter mask is unnecessary. It implies that a particulate filter mask is needed, which it is not for droplet precautions. This option also incorrectly suggests that vital signs can be obtained with a standard mask, but personal care requires a particulate filter mask, which is not accurate.

C) Droplet precautions require the use of a standard face mask, not a particulate filter mask (such as an N95 respirator). Particulate filter masks are required for airborne precautions, which are necessary for diseases like tuberculosis, measles, or chickenpox. For droplet precautions, a standard surgical mask is adequate to prevent the transmission of infections like influenza. Thus, the UAP can safely provide care to the client with flu-like symptoms by wearing a standard face mask.

D) This option is unnecessary because a particulate filter mask is not required for droplet precautions. Changing assignments based on this criterion is not needed and could disrupt the workflow without enhancing safety. The focus should be on ensuring staff understand and use the appropriate PPE for droplet precautions.

A. Observe for swelling at the fracture site. B. Analyze the cardiac rhythm in another lead. C. Obtain a 12-lead electrocardiogram. D. Begin chest compressions at 100/minute.

Correct Answer is D

Explanation

A) Incorrect- Observing for swelling at the fracture site is important for assessing the client's musculoskeletal condition, but it is not the priority intervention in this situation. The absence of spontaneous respirations and palpable carotid pulse indicates cardiac arrest, and immediate intervention is needed.

B) Incorrect- Analyzing the cardiac rhythm in another lead is not the first priority when the client is in cardiac arrest. Cardiopulmonary resuscitation (CPR) should be initiated immediately to restore circulation.
C) Incorrect- Obtaining a 12-lead electrocardiogram is not the initial intervention in a client in cardiac arrest. CPR and defibrillation (if indicated) are the immediate actions to provide circulation and oxygenation to the vital organs.
D) Correct- The absence of spontaneous respirations and palpable carotid pulse indicates cardiac arrest. In this situation, immediate initiation of cardiopulmonary resuscitation (CPR) is critical to provide circulation and oxygenation to the vital organs. Chest compressions are the initial step to address cardiac arrest and ensure blood flow to the body.

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Naxlex Comprehensive Predictor Exams

An unlicensed assistive personnel (UAP) is assigned to a client with flu-like symptoms who has been placed on droplet precautions. The UAP requests a change in assignment, stating she has not yet been fitted for a particulate filter mask. Which action should the nurse take?

Correct Answer is C

Explanation

When the nurse enters the room of a male client who was admitted for a fractured femur, his cardiac monitor displays a normal sinus rhythm (NSR), but he has no spontaneous respirations and his carotid pulse is not palpable. Which intervention should the nurse implement?

Correct Answer is D

Explanation

Exhibits Click to mark whether the following are signs and symptoms of cerebral edema, respiratory distress, or both.

The nurse is preparing to send a client to the cardiac catheterization lab for an angioplasty. Which client report is most important for the nurse to explore further prior to the start of the procedure?

Exhibits The nurse reviews the physician's orders for clonazepam and gives the medication as ordered. What nursing interventions are appropriate for the client starting clonazepam? Select all that apply.

A client with foul-smelling drainage from an incision on the upper left arm is admitted with a suspected methicillin-resistant Staphylococcus aureus (MRSA). Which nursing intervention(s) should the nurse include in the plan of care? (Select all that apply.)

The healthcare provider prescribes 500 mL intravenous (IV) bolus of 0.9% normal saline to be infused over 30 minutes. How many mL/hour should the nurse set the infusion pump? (Enter numerical value only.)

An older woman who has difficulty hearing is being discharged from day surgery following a cataract extraction and lens implantation. Which intervention is most important for the nurse to implement to help ensure the client's compliance with self-care?

A 3-year-old boy with a congenital heart defect is brought to the clinic by his mother because he has a fever and an earache. During the assessment, the mother asks the nurse why her child is at the 5th percentile for weight and height for his age. Which response is best for the nurse to provide?

The nurse is providing discharge teaching to a client who underwent a pneumonectomy. The client wants to resume social activities with family. How should the nurse respond?