A nurse observes a parent administer a prescribed oral medication to an infant. Which of the following statements indicates a need for further instruction?
Administers medication with an oral syringe.
Inserts the medication in the infant’s buccal cavity.
Allows the infant to swallow some of the medication before administering more.
Positions the infant in a supine position.
The Correct Answer is D
Choice A reason:
Administering medication with an oral syringe is a recommended practice for giving liquid medication to infants. An oral syringe allows for accurate measurement and controlled delivery of the medication, reducing the risk of choking and ensuring the infant receives the correct dose. Therefore, this statement does not indicate a need for further instruction.
Choice B reason:
Inserting the medication in the infant’s buccal cavity (the space between the gums and the cheek) is also a recommended technique. This method helps to prevent the infant from spitting out the medication and ensures better absorption. Hence, this statement does not indicate a need for further instruction.
Choice C reason:
Allowing the infant to swallow some of the medication before administering more is a safe and effective way to give medication. This approach helps to prevent choking and ensures that the infant can handle the amount of medication being given. Therefore, this statement does not indicate a need for further instruction.
Choice D reason:
Positioning the infant in a supine position (lying flat on their back) is not recommended when administering oral medication. This position increases the risk of aspiration, where the medication could enter the airway instead of the esophagus. The correct position is to hold the infant in an upright or semi-upright position to ensure safe swallowing and reduce the risk of choking or aspiration. Therefore, this statement indicates a need for further instruction.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Babinski’s sign
Babinski’s sign is a reflex action where the big toe moves upward or toward the top surface of the foot and the other toes fan out when the sole of the foot is stimulated. This sign is used to assess neurological function, particularly in the context of central nervous system disorders. It is not related to hypocalcemia, which is the likely cause of the tingling sensation in this scenario.
Choice B reason: Chvostek’s sign
Chvostek’s sign is a clinical indicator of hypocalcemia. It is elicited by tapping the facial nerve at the angle of the jaw, which causes twitching of the facial muscles. Hypocalcemia is a common complication following thyroidectomy due to potential damage or removal of the parathyroid glands, which regulate calcium levels. The tingling sensation reported by the client is a classic symptom of hypocalcemia, making Chvostek’s sign the most relevant assessment.
Choice C reason: Brudzinski’s sign
Brudzinski’s sign is used to assess for meningitis. It involves flexing the client’s neck and observing for involuntary flexion of the hips and knees. This sign is not related to hypocalcemia or the symptoms described by the client following thyroidectomy.
Choice D reason: Kernig’s sign
Kernig’s sign is another test for meningitis. It involves flexing the client’s hip and knee, then straightening the knee. Pain and resistance to straightening the knee indicate a positive Kernig’s sign. This sign is not relevant to the assessment of hypocalcemia or the symptoms described by the client.
Correct Answer is ["B","C","D","E"]
Explanation
Choice A reason: Applying restraints if the client becomes agitated should be done with caution and only as a last resort. Restraints can increase the risk of injury and should be used according to hospital policy and only when absolutely necessary. Alternative methods to calm the client should be explored first.
Choice B reason: Administering pantoprazole as prescribed is important to prevent stress ulcers and gastrointestinal bleeding, which are common complications in clients receiving mechanical ventilation. Pantoprazole is a proton pump inhibitor that reduces stomach acid production.
Choice C reason: Verifying the prescribed ventilator settings daily is crucial to ensure the client is receiving the correct ventilation support. Regular checks help identify any discrepancies or changes in the client’s condition that may require adjustments to the ventilator settings.
Choice D reason: Elevating the head of the bed to at least 30 degrees helps prevent ventilator-associated pneumonia (VAP) by reducing the risk of aspiration. This position also aids in lung expansion and improves oxygenation.
Choice E reason: Repositioning the endotracheal tube to the opposite side of the mouth daily helps prevent pressure ulcers and sores in the mouth. Regular repositioning reduces the risk of tissue damage and infection.
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