A nurse is assisting with the care of a 5-month-old infant who was just admitted to the pediatric unit.
For each potential provider's prescription, click to specify if the potential prescription is anticipated or contraindicated for the infant.
Maintain infant on continuous pulse oximetry.
Prepare the infant for a chest x-ray.
Initiate a peripheral IV line.
Maintain infant in supine position.
Offer small, frequent feedings.
Monitor intake and output.
The Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"A"},"F":{"answers":"A"}}
Continuous pulse oximetry: Anticipated because the infant has respiratory distress and requires continuous monitoring of oxygen saturation.
Chest x-ray: Anticipated to assess the extent of lung involvement due to the respiratory distress and wheezing noted.
Peripheral IV line: Anticipated since the peripheral line will be used to administer intravenous medications and fluids.
Supine position: Contraindicated because the infant prefers to sit upright and shows signs of respiratory distress, such as nasal flaring and retractions.
Small, frequent feedings: Anticipated to ensure adequate nutrition despite feeding difficulties.
Monitor intake and output: Anticipated to assess hydration status, especially since the infant has had decreased intake and output.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is []
Explanation
Potential Condition: Increased intracranial pressure
Actions to Take:
Measure head circumference: This action is important to monitor for signs of increasing intracranial pressure, as a bulging and tense fontanel suggests possible hydrocephalus or other intracranial pathology.
Plan to assist with administration of antibiotics: Antibiotics may be necessary if there is suspected meningitis or another infectious cause contributing to increased intracranial pressure.
Parameters to Monitor:
Behavioral changes: Monitor for irritability, difficulty to console, and other behavioral changes which can indicate neurological distress.
Pupillary response: Assess for changes in pupillary size and reactivity, as altered pupillary responses can indicate neurological involvement and increased intracranial pressure.
Correct Answer is B
Explanation
A. Corticosteroid ointment is not recommended for viral conjunctivitis as it can exacerbate the infection or prolong the healing process. Viral conjunctivitis typically resolves on its own without the need for corticosteroids.
B. Cleaning the eye by wiping downward and outward from the inner canthus helps to remove discharge and prevent the spread of infection. This technique ensures that contaminants are removed efficiently and reduces the risk of re-infection.
C. Antibiotic eye ointment is not indicated for viral conjunctivitis, as antibiotics are ineffective against viruses. Treatment typically focuses on symptom relief rather than antibacterial therapy.
D. While cool compresses can provide symptom relief, continuous application is not necessary. Intermittent cool compresses may help to soothe irritation and reduce swelling, but continuous use is not required.
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