A nurse is contributing to the plan of care for a newly admitted adolescent.
A nurse is contributing to the plan of care for a newly admitted adolescent. Which of the following interventions should the nurse include?
Suction the client's airway every 2 hr.
Maintain the client's head of the bed at 30°.
Keep the client's room well lit.
Check the client's temperature every 8 hr.
The Correct Answer is B
A: Suctioning the client's airway every 2 hours is not indicated based on the provided information. The adolescent does not have a condition that compromises airway clearance, and routine suctioning can cause trauma or stimulate a vagal response, potentially leading to bradycardia.
B: Maintaining the client's head of the bed at 30° is appropriate for reducing intracranial pressure and facilitating venous drainage. The patient's symptoms of nuchal rigidity and severe headache suggest increased intracranial pressure, possibly due to meningitis, which is supported by the diagnostic results.
C: Keeping the client's room well lit is not advisable as the patient reports photophobia, which is a sensitivity to light. A well-lit room could exacerbate discomfort and pain.
D: Checking the client's temperature every 8 hours is important but not the priority intervention. The patient's condition requires more frequent monitoring due to the positive blood culture and sensitivity, indicating an active infection. More frequent temperature checks would be warranted.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason:
Placing a urine collection device on the infant is not an appropriate method for collecting a stool specimen.
Choice B reason:
Obtaining the specimen by swabbing the infant's rectum using a sterile culture swab is the correct method for collecting a stool specimen from an infant.
Choice C reason:
Maintaining the specimen at room temperature is appropriate after collection until it is transferred to the lab. This is standard procedure for many specimens.
Choice D reason:
Using povidone-iodine-soaked gauze is not a standard method for transferring a stool specimen to the collection container.
Correct Answer is B
Explanation
Choice A reason:
Placing a folded blanket to pad the back of the infant's head is not recommended, as it can interfere with the proper fit of the car seat harness and potentially be a safety hazard.
Choice B reason:
This statement is correct. Infant car seats should be positioned at a 30-degree angle to provide optimal support for the infant's head and neck, as well as to prevent airway obstruction.
Choice C reason:
While car seats with a four-point harness do exist, a standard infant car seat typically has a five- point harness system.
Choice D reason:
The retainer clip should be positioned at the level of the infant's armpits to ensure that the harness is snug and secure.
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