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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct answer ischoice A.
Choice A rationale:
Having the client vocalize the instructions provided ensures that they have understood the information correctly.This method allows the nurse to confirm comprehension and clarify any misunderstandings.
Choice B rationale:
Providing written instructions for eye drop administration is helpful but does not ensure that the client understands the instructions.It is a good supplementary measure but should not be the sole method of communication.
Choice C rationale:
Speaking clearly and facing the client for lip reading is important, especially for clients with hearing impairments.However, it does not guarantee that the client has understood the instructions.
Choice D rationale:
Ensuring that someone will stay with the client for 24 hours is a good safety measure but does not directly address the client’s understanding of the discharge instructions.
Correct Answer is D
Explanation
NPO status is crucial before a surgical procedure, especially when anesthesia will be administered. It helps prevent complications related to aspiration of gastric contents during the procedure. Failure to adhere to the NPO status can lead to serious respiratory problems, such as aspiration pneumonia.
It is important for the nurse to confirm the NPO status with the client to ensure that they have followed the appropriate fasting guidelines. This should be done to ensure the client's safety during the surgery.
While determining when the client last had pain medication, offering assistance to the restroom, and reviewing postoperative instructions are important aspects of preoperative care, confirming NPO status is the most critical nursing action in this particular scenario.
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