A nurse is caring for an infant in the post-anesthesia care unit following cleft lip and palate repair. What is an appropriate action for the nurse to take?
Offer a pacifier with sucrose for pain relief.
Maintain elbow restraints in the postoperative period.
Place infant in trendelenburg position in the immediate postoperative period.
Provide an ice collar for pain.
The Correct Answer is B
A. Offering a pacifier is contraindicated after cleft lip and palate repair as it can disrupt the surgical site and interfere with healing.
B. Maintaining elbow restraints prevents the infant from touching or putting objects in their mouth, which could disrupt the surgical site and compromise healing.
C. The Trendelenburg position is not recommended as it can increase pressure on the surgical site and compromise breathing.
D. An ice collar may be used for pain relief in older children or adults but is not typically used in infants, and it may not be feasible in this population.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. PKU is typically diagnosed through a blood test, not a urine test. The blood test measures phenylalanine levels, which are elevated in PKU.
B. Untreated PKU can lead to severe cognitive deficits and developmental delays due to the accumulation of phenylalanine, which is toxic to the brain. Early detection and treatment can prevent these outcomes.
C. In PKU, the urine does not typically contain high levels of phenyl pyruvic acid; it is the blood levels of phenylalanine that are elevated.
D. The effects of PKU are not reversible; however, with early and consistent treatment, such as a strict low-phenylalanine diet, the symptoms can be managed effectively.
Correct Answer is A
Explanation
A. Keeping a dedicated thermometer in the toddler's room is an appropriate infection control measure to prevent cross-contamination with other patients.
B. RSV is primarily transmitted through droplet and contact, not airborne, so contact and droplet precautions are more appropriate than airborne precautions.
C. Nebulized racemic epinephrine is not typically used for RSV; it is more commonly used for croup. Treatment for RSV may include supportive care such as hydration and oxygen therapy.
D. While monitoring pulse oximetry is important, assessing it every 3 hours might be insufficient. Continuous monitoring may be more appropriate depending on the severity of the illness.
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