A nurse is preparing to administer nystatin oral suspension to an infant who has oral candidiasis. Which of the following actions should the nurs take?

Give the dose of medication in the infant's bottle.

Educate the caregiver to avoid breastfeeding

Administer the medication before the infant's feeding

Distribute the medication on the infant's oral mucosa.

Answer and Explanation

The Correct Answer is D

Rationale:

A. Give the dose of medication in the infant's bottle: Placing nystatin in a bottle may result in incomplete dosing, as the infant may not consume the full amount. This method also limits the medication's contact time with the affected mucosa, reducing its effectiveness.

B. Educate the caregiver to avoid breastfeeding: Breastfeeding should not be avoided unless the mother has signs of candidiasis on the breast. Instead, both mother and infant should be treated simultaneously if either shows symptoms to prevent reinfection.

C. Administer the medication before the infant's feeding: Administering nystatin before feeding may cause the medication to be washed away by milk, decreasing mucosal contact time. It is generally recommended after feeding to ensure prolonged exposure to the mucosa.

D. Distribute the medication on the infant's oral mucosa: Applying the suspension directly to the affected areas allows the antifungal to coat the mucosa thoroughly, maximizing effectiveness. It is the preferred method to treat oral candidiasis in infants.

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Correct Answer is ["A","C","D"]

Explanation

Rationale:

• Examine the client's nail beds: Assessing nail beds for cyanosis provides visual clues of hypoxia. This is a noninvasive, rapid method to evaluate tissue perfusion and oxygenation. The client's saturations are borderline low despite increasing oxygen.

• Place the client in the supine position: The supine position can reduce lung expansion and worsen hypoxia, especially after sedation. Elevating the head of the bed promotes lung expansion and better diaphragmatic movement.

• Encourage client to perform deep breathing exercises: Deep breathing helps expand alveoli and improves oxygen exchange. It may reduce the need for higher oxygen delivery if the hypoxia is due to shallow respirations after sedation.

• Prepare to administer oxygen via Venturi face mask: The client's O₂ saturation is dropping despite nasal cannula at 5 L/min. A Venturi mask delivers a more precise and consistent oxygen concentration, making it appropriate here.

• Add a humidifier to the oxygen device: Humidification is generally needed for oxygen above 4 L/min over long durations. This client has only been on oxygen for a short time post-procedure, so humidification is not urgently required.

A. "The client in room 205 has had several visitors today." B. "The client in room 204 received some pain medicine earlier today." C. "The client in room 205 is scheduled for a dressing change at 1800 D. "The client in room 203 will undergo surgery at 0900 tomorrow." E. "The client in room 204 has a new prescription for IV gentamicin”

Correct Answer is ["C","D","E"]

Explanation

Rationale:

A. "The client in room 205 has had several visitors today." This is non-essential social information that does not contribute to continuity of care or clinical decision-making. Change-of-shift reports should focus on relevant clinical updates and care plans.

B. "The client in room 204 received some pain medicine earlier today." This statement lacks specificity, such as the type, dosage, time, and client response to the medication. Without detailed clinical context, the information is not useful for ensuring safe, consistent care.

C. "The client in room 205 is scheduled for a dressing change at 1800." This provides specific, actionable information that the oncoming nurse needs to know in order to follow the treatment plan and ensure timely wound care.

D. "The client in room 203 will undergo surgery at 0900 tomorrow." This is essential procedural information that allows the next nurse to prepare the client appropriately and monitor for any pre-op needs, such as NPO status or lab work.

E. "The client in room 204 has a new prescription for IV gentamicin." This communicates a significant change in the client’s medication regimen, which may require monitoring for side effects, such as nephrotoxicity or ototoxicity, making it critical to include in report.

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A nurse is preparing to administer nystatin oral suspension to an infant who has oral candidiasis. Which of the following actions should the nurs take?

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