A nurse is caring for a 2-month-old infant in a crib and needs the nasogastric tube on the counter near the sink. The nurse would now:.

Assess the infant's ability to roll over.

Put a nesting pillow around the infant.

Put the side rail all the way up.

Call for someone else to get the tube.

Answer and Explanation

The Correct Answer is D

Choice A rationale:

Assessing the infant's ability to roll over is unrelated to the situation. The nurse's focus should be on safely retrieving the nasogastric tube without leaving the infant alone.

Choice B rationale:

Using a nesting pillow is not appropriate in this scenario. The nurse should prioritize getting the nasogastric tube rather than introducing unnecessary items into the crib.

Choice C rationale:

Putting the side rail all the way up might hinder the nurse's ability to access the counter and the nasogastric tube. It is not the most effective action in this situation.

Choice D rationale:

Calling for assistance ensures that the infant's safety is maintained while the nurse retrieves the nasogastric tube. Leaving the infant unattended increases the risk of harm, so involving someone else is the appropriate action.

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Correct Answer is B

Explanation

Minimize crying.

Choice A rationale:

Encouraging attachment might be important for the child's emotional well-being, but in the immediate postoperative period after cleft lip repair, minimizing crying takes priority. Crying can place stress on the suture line and disrupt the healing process.

Choice B rationale:

Minimizing crying is crucial to prevent tension on the suture line and ensure proper healing of the cleft lip repair. Excessive crying can lead to increased pressure on the surgical site and potential complications. Elbow restraints are applied to prevent the child from touching the surgical site, so minimizing crying helps to maintain the effectiveness of these restraints.

Choice C rationale:

Restricting oral intake is not a priority in this case. While it's important to ensure the child doesn't consume anything that might harm the surgical site, it's not the highest priority action compared to preventing tension on the suture line.

Choice D rationale:

Initiating range of motion is not the priority postoperative intervention for a cleft lip repair. The primary concern at this stage is to prevent disruption of the surgical site and ensure proper healing, making minimizing crying a higher priority.

A. Give the patient a soft tissue to clean up the drainage. B. Check the drainage for glucose content. C. Obtain a specimen of the drainage for culture and sensitivity. D. Ask the father if the patient had nasal drainage before his injury.

Correct Answer is B

Explanation

Choice A rationale:

Giving the patient a soft tissue is not the initial action to take when dealing with clear liquid drainage from the nose. Assessing the content of the drainage is more crucial for appropriate management.

Choice B rationale:

Checking the drainage for glucose content is essential because the presence of glucose indicates that the drainage is cerebrospinal fluid (CSF), which can occur with a skull fracture that involves the base of the skull.

Choice C rationale:

Obtaining a specimen of the drainage for culture and sensitivity is important, but it is not the initial action. Confirming the nature of the drainage takes precedence.

Choice D rationale:

Asking the father about nasal drainage before the injury is not as relevant as assessing the current drainage, which could be indicative of a CSF leak.

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A nurse is caring for a 2-month-old infant in a crib and needs the nasogastric tube on the counter near the sink. The nurse would now:.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client is transferred to the pediatric unit after repair of a cleft lip. The child has a Logan bow in place over the suture line and has elbow restraints applied to both arms. Which nursing intervention should take priority in her postoperative care plan?

Correct Answer is B

Explanation

A 3-year-old patient who is admitted to the hospital for the treatment of a skull fracture has clear liquid draining from his nose. In consideration of the patient's injury, which action should the nurse take initially?

Correct Answer is B

Explanation

An 11-year-old patient with sickle cell anemia is admitted to the hospital with vaso-occlusive crisis. He is experiencing pain in his left elbow. The nurse needs to monitor the patient for which symptom?

What information should a nurse plan to give the parents of a 9-month-old infant who is to be discharged after a cleft palate repair?

The nurse is caring for a pediatric patient receiving digoxin therapy. Which assessment finding would indicate digoxin toxicity?

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A 7-year-old patient has been admitted to the hospital with a ruptured appendix. Which action should the nurse take while awaiting surgery?

When assessing an infant with moderate dehydration, a nurse would expect which assessment findings?

What statement made by the caregivers reflects an understanding of proper nutrition for their newborn?

A 15-year-old patient with a closed head injury is admitted to the pediatric intensive care unit and is intubated. The nurse should monitor the patient for which symptom?