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 D
Explanation
When determining that Bryant's traction is appropriately assembled, the nurse should observe that the buttocks is elevated slightly off of the bed.
In Bryant traction, both of the patient’s limbs are suspended in the air vertically at a ninety-degree angle from the hips and knees slightly flexed.
Choice A is incorrect because a padded sling is not used under the knee of the affected leg in Bryant traction.
Choice B is incorrect because skin straps are not used to maintain the leg in an
extended position in Bryant traction.
Choice C is incorrect because weights are not attached to a pin that is inserted into the femur in Bryant traction.
Correct Answer is B
Explanation
This response is appropriate because it informs the parent that the nurse has a legal obligation to report any suspected child abuse.
Choice A is not an answer because it does not address the parent’s concern and instead defers responsibility to the provider.
Choice C is not an answer because it does not provide any information to the parent and instead suggests contacting a supervisor.
Choice D is not an answer because it implies that the decision to report the incident was made by the supervisor and not the nurse.
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