A nurse is caring for an infant who is postoperative following repair of a cleft palate. Which of the following is an appropriate action by the nurse?
Gently cleanse the surgical site with sterile gauze.
Place the infant in a supine position.
Apply elbow immobilizers to both arms.
Offer a pacifier with glucose syrup.
The Correct Answer is C
A. Cleansing the surgical site is not typically recommended as it can interfere with healing and cause trauma to the area. The surgical site should be kept clean and dry according to the surgeon's instructions.
B. Placing the infant in a supine position is not recommended as it can increase the risk of aspiration and disrupt the surgical site. Positioning should be done to protect the surgical repair.
C. Applying elbow immobilizers to both arms prevents the infant from touching or putting their hands in their mouth, which helps to protect the surgical site from injury and allows it to heal properly.
D. Offering a pacifier with glucose syrup is not appropriate as sucking on a pacifier can disrupt the surgical site and glucose syrup is not necessary in this situation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. BUN level of 12 mg/dL is within normal range and does not indicate infection.
B. Urine specific gravity of 1.014 is within normal range and does not indicate infection.
C. A WBC count of 17,500/µL is elevated and indicates a possible infection, which should be reported immediately.
D. Urine osmolality of 500 mOsm/kg is within normal range and does not indicate infection.
Correct Answer is B
Explanation
A. Alanine aminotransferase (ALT) is a liver enzyme and not typically relevant for diagnosing juvenile idiopathic arthritis.
B. Erythrocyte sedimentation rate (ESR) is a marker of inflammation and is commonly used in the evaluation and monitoring of juvenile idiopathic arthritis.
C. Potassium levels are not directly related to juvenile idiopathic arthritis and its diagnosis.
D. BUN (blood urea nitrogen) is a measure of kidney function and is not specific to juvenile idiopathic arthritis.
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