A nurse is caring for an infant in a provider's office.
Medical History Provider Visit #1. Heart rate 144/min.
Axillary temperature 39.7° C (103.5°F). Respiratory rate 32/min.
Oxygen saturation 95% on room air. Provider Visit #2 (4 days later).
Axillary temperature 37.4° C (99.3° F). Heart rate 132/min.
Respiratory rate 28/min.
Oxygen saturation 97% on room air.
Which of the following actions should the nurse plan to take? Select the actions the nurse should plan to take.
Teach caregivers to change diapers when wet.
Have caregivers administer 16 oz of water after each diarrhea stool.
Cleanse the diaper area with soap and water.
Collect nasal drainage for culture and sensitivity.
Teach caregivers to apply talcum powder to creases.
Use a nasal aspirator after feedings.
Correct Answer : A,C
Choice A rationale: Teaching caregivers to change diapers immediately when wet is essential for preventing skin breakdown and secondary infections, especially when an infant has been experiencing high fevers or potential gastrointestinal distress.
Choice B rationale: Administering 16 oz of water to an infant after each stool is dangerous. Infants are at high risk for water intoxication and electrolyte imbalances; rehydration should involve breast milk, formula, or oral rehydration solutions.
Choice C rationale: Cleansing the diaper area with mild soap and water is a standard nursing intervention to maintain skin integrity. It removes irritants and bacteria effectively, reducing the risk of developing a secondary diaper dermatitis.
Choice D rationale: Collecting nasal drainage for culture is not indicated based on the provided vital signs. The infant's temperature has improved, and there is no specific evidence of a worsening respiratory infection requiring a culture.
Choice F rationale: Caregivers should never apply talcum powder to an infant’s skin creases. Talcum powder poses a significant aspiration risk and can lead to severe respiratory distress or chronic lung irritation if inhaled.
Choice G rationale: Using a nasal aspirator should be done before feedings, not after. Suctioning after a feeding can trigger the gag reflex and cause the infant to vomit, increasing the risk of aspiration.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Behavioral approaches have the most evidence for treating symptoms of Autism
Spectrum Disorder (ASD)1.
Applied Behavior Analysis (ABA) is a notable behavioral treatment for people with ASD that encourages desired behaviors and discourages undesired behaviors to improve a variety of skills.
A reward system for positive behavior is an example of an ABA technique.
Choice A is not correct because allowing for imaginative play with peers without supervision is not a recommended intervention for a child with ASD.
Choice C is not correct because providing a flexible schedule that adjusts to the child’s interests is not a recommended intervention for a child with ASD.
Choice D is not correct because allowing for adjustment of rules to correlate with the child’s behavior is not a recommended intervention for a child with ASD.
Correct Answer is D
Explanation
Individuals with spina bifida who are paralyzed from the waist down may have difficulty emptying their bladder completely and may need to perform intermittent catheterization.
The frequency of catheterization can vary depending on the individual’s needs, but it is typically performed every 3-6 hours or 4-6 times per day.
Choice A, “I do wheelchair exercises while watching TV,” is a positive statement because exercise is important for overall health and well-being.
Choice B, “I carry a water bottle with me because I drink a lot of water,” is also a positive statement because staying hydrated is important for overall health.
Choice C, “I use a suppository every night to have a bowel movement,” is not necessarily an indication for further teaching because some individuals with spinal bifida may need to use bowel management techniques such as suppositories to help regulate bowel movements.
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