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 3 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 : C,D,E
Choice C, cleanse diaper area with soap and water, is important to maintain hygiene and prevent diaper rash. This should be done at each diaper change.
Choice E, instruct caregivers to apply zinc oxide with each diaper change, is important to prevent diaper rash and promote healing if a rash is present.
Choice D, collect nasal drainage for culture and sensi vity, is important to determine if there is a bacterial infec on present, which could explain theinfant's high fever during the first provider visit.
Choice A, teach caregivers to change diaper when wet, is not necessary as it is already expected that caregivers will change the diaper when wet.
Choice B, have caregivers administer 16 oz of water a er each diarrhea stool, is not necessary as there is no indica on of diarrhea in the scenario.
Choice F, teach caregivers to apply talcum powder to creases, is not necessary as talcum powder has been associated with respiratory problems in infants and should not be used.
Choice G, use a nasal aspirator a er feedings, is not necessary as there is no indica on of nasal conges on in the scenario.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["C","D","E"]
Explanation
Choice C, cleanse diaper area with soap and water, is important to maintain hygiene and prevent diaper rash. This should be done at each diaper change.
Choice E, instruct caregivers to apply zinc oxide with each diaper change, is important to prevent diaper rash and promote healing if a rash is present.
Choice D, collect nasal drainage for culture and sensi vity, is important to determine if there is a bacterial infec on present, which could explain theinfant's high fever during the first provider visit.
Choice A, teach caregivers to change diaper when wet, is not necessary as it is already expected that caregivers will change the diaper when wet.
Choice B, have caregivers administer 16 oz of water a er each diarrhea stool, is not necessary as there is no indica on of diarrhea in the scenario.
Choice F, teach caregivers to apply talcum powder to creases, is not necessary as talcum powder has been associated with respiratory problems in infants and should not be used.
Choice G, use a nasal aspirator a er feedings, is not necessary as there is no indica on of nasal conges on in the scenario.
Correct Answer is B
Explanation
The correct answer is choiceb. Firmly attached white particles on the hair.
Choice A rationale:
Itching and scratching of the head are common symptoms of pediculosis capitis, but they are not definitive indicators. Itching can be caused by various other conditions such as dandruff or allergies.
Choice B rationale:
Firmly attached white particles on the hair, known as nits, are a definitive sign of pediculosis capitis.Nits are lice eggs that stick to the hair shafts and are difficult to remove.
Choice C rationale:
Thick yellow crusted lesions on a red base are more indicative of impetigo, a bacterial skin infection, rather than pediculosis capitis.
Choice D rationale:
Patchy areas of hair loss are typically associated with conditions like alopecia areata or fungal infections such as tinea capitis, not pediculosis capitis.
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