A nurse is caring for a 4-month-old infant who is one day postoperative following surgical repair of a cleft lip. Which of the following actions should the nurse take? Select all that apply

Position the infant on their back and upright in Semi-Fowler's

Encourage the parents told the baby

Administer aspirin for pain

Apply elbow restraints as ordered

Maintain IV therapy for nutrition

Answer and Explanation

Correct Answer : A,D,E

A. Positioning the infant on their back and upright in Semi-Fowler's helps prevent aspiration and supports respiratory function after surgery.

B. Encouraging parents to hold the baby is important for bonding, but caution should be taken to avoid placing pressure on the surgical site.

C. Aspirin should not be administered due to the risk of Reye's syndrome; acetaminophen is typically used for pain management in infants.

D. Applying elbow restraints as ordered is necessary to prevent the infant from pulling at the surgical site and to ensure proper healing.

E. Maintaining IV therapy is crucial for nutrition until the infant can take oral feeds safely.

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Correct Answer is B

Explanation

A. While clear chicken broth can provide some hydration, it does not contain the necessary electrolytes to replace losses effectively.

B. Initiating oral rehydration therapy is critical for managing dehydration due to diarrhea and is the best approach for a child in this situation.

C. Starting a hypertonic solution is inappropriate and could lead to further dehydration or electrolyte imbalances.

D. Keeping the child NPO is not necessary; it is more important to maintain hydration and possibly offer oral rehydration solutions.

A. Administering an intermittent IV bolus medication B. Talking to the client at the bedside C. Administering an IM injection D. Completing a dressing change

Correct Answer is D

Explanation

A. Administering an IV bolus medication does not typically require gowning unless there is a risk of exposure to bodily fluids.

B. Talking to the client does not necessitate wearing a gown, as it does not pose a risk of exposure.

C. Administering an IM injection may require gloves but not necessarily a gown unless there is a risk of splashing.

D. Completing a dressing change involves potential exposure to bodily fluids, so wearing a gown is appropriate for infection control.

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A nurse is caring for a 4-month-old infant who is one day postoperative following surgical repair of a cleft lip. Which of the following actions should the nurse take? Select all that apply

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a year old child who has had watery diarrhea for the past 3 days. Which of the following is the most appropriate action for the nurse to take?

Correct Answer is B

Explanation

A nurse is caring for a client who is HIV positive and is one day postoperative following an appendectomy. The nurse should wear a gown as personal protective equipment when taking which of the following actions?

Correct Answer is D

Explanation

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