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.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

The correct answer is choice D. Demonstrate to the PN how to position the client more effectively for the procedure.

Choice A rationale:

Arranging for unlicensed assistive personnel to assist the PN during the procedure does not address the incorrect positioning of the client. The priority is to ensure the client is positioned correctly for the sigmoidoscopy, which is typically on the left side with knees drawn toward the chest.

Choice B rationale:

Acknowledging that the PN has positioned the client safely and correctly is not appropriate because the flat prone position is incorrect for a sigmoidoscopy. The correct position is on the left side with knees drawn toward the chest.

Choice C rationale:

Assuming care of the client and assigning the PN to the care of a different client does not address the educational opportunity. It is important to demonstrate the correct positioning to the PN to ensure proper care in future procedures.

Choice D rationale:

Demonstrating to the PN how to position the client more effectively for the procedure is the correct action. This ensures the client is in the proper position for the sigmoidoscopy and provides an educational opportunity for the PN.

A. Limit calories on days unable to exercise. B. Monitor blood glucose levels daily. C. Regular exercise with medical approval. D. Monthly appointments with the dietitian.

Correct Answer is C

Explanation

Regular exercise is a vital component of managing type 2 diabetes. It helps to lower blood glucose levels, improve insulin sensitivity, and increase HDL (the "good" cholesterol) levels. However, it is important for the client to obtain medical approval before starting or modifying an exercise regimen. The healthcare provider can assess the client's overall health status and provide specific recommendations regarding the type, duration, and intensity of exercise suitable for the client's individual needs and any potential limitations.

Limiting calories on days unable to exercise is a valid strategy for managing weight and blood glucose levels; however, it is not specifically related to increasing HDL levels. It is important to maintain a balanced and healthy diet overall.

Monitoring blood glucose levels daily is an important self-care practice for individuals with diabetes, but it is not specifically focused on increasing HDL levels. Blood glucose monitoring helps to assess the effectiveness of diabetes management and make necessary adjustments to medication, diet, or exercise.

Monthly appointments with the dietitian can be beneficial for diabetes management, as dietary modifications play a significant role. However, the instruction regarding exercise is more directly related to increasing HDL levels, and the frequency of appointments with the dietitian may vary based on individual needs and goals.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is setting up the equipment to assist with a sigmoidoscopy while the practical nurse (PN) positions the client in a flat prone position. Which action should the nurse implement?

Correct Answer is D

Explanation

The nurse is developing a plan of care for a client with type 2 diabetes mellitus (DM). When providing teaching on lowering blood glucose levels and increasing serum high-density lipoprotein (HDL) levels, which instruction should the nurse include?

Correct Answer is C

Explanation

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.

The nurse implements a primary prevention program for sexually transmitted diseases in a nurse-managed health center. Which outcome Indicates that the program was effective?

When planning care for an adolescent with anorexia nervosa, which nursing problem has the highest priority?

The nurse is planning to administer two medications to a client at 0900. Which property of the drugs, if shared by both drugs, indicates a need to closely monitor the client for drug toxicity?

The charge nurse is making assignments for one practical nurse (PN) and three registered nurses (RN) who are caring for neurologically compromised clients. Which client with which change in status is best to assign to the PN?

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?

Patient Data History and Physical Nurses' Notes Laboratory Results Flow Sheet Exhibits here Review H and P, nurse's note, laboratory result, and flow sheet. What information should the nurse collect as part of the focused assessment for dehydration in this child? Select all that apply.