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 A
Explanation
Nursing care planning goals for a child with acute glomerulonephritis are directed toward the excretion of excess fluid through urination.
Monitoring fluid status is very important and daily weights are an effective way to monitor fluid retention, as weight gain is the earliest sign of fluid retention.
Choice B, Educating the parents about potential complications, is important but not the nurse’s priority.
Choice C, Place the child on a no-salt-added diet, which may be part of the treatment
plan but is not the nurse’s priority.
Choice D, Maintaining a saline lock, may be necessary for administering medications but is not the nurse’s priority.
Correct Answer is ["B","D","E"]
Explanation
Preschool-age children often have a limited understanding of death and may believe that their thoughts can cause death.
They may also view death as similar to sleep 1 and may think that death is a punishment.
Choice A is not correct because preschool-age children may not necessarily be interested in what happens to the body after death.
Choice C is not correct because preschool-age children usually do not recognize that death is permanent.
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