The parents of a male infant newborn have signed an informed consent for circumcision. Which priority intervention should the nurse implement upon completion of the circumcision procedure?

Give a PRN prescribed dose of liquid acetaminophen.

Wrap the infant in a warm receiving blankets.

Offer a pacifier dipped in glucose water.

Place petrolatum applied gauze dressings on the circumcision site.

Answer and Explanation

The Correct Answer is D

Choice A reason: Acetaminophen reduces pain but is secondary to preventing infection and bleeding with petrolatum dressings. Dressings are the immediate post-circumcision priority to protect the surgical site, per circumcision care and infection control protocols in neonatal nursing practice.

Choice B reason: Wrapping in blankets maintains warmth but does not address the surgical site’s immediate needs. Petrolatum dressings prevent infection and adhesion, critical post-circumcision. Warmth is secondary, per circumcision care and neonatal thermoregulation standards in nursing practice.

Choice C reason: Offering a glucose-dipped pacifier soothes but does not protect the circumcision site from infection or bleeding. Petrolatum dressings are the priority to ensure healing and comfort, per circumcision care and postoperative pain management standards in neonatal nursing practice.

Choice D reason: Applying petrolatum gauze dressings prevents infection, promotes healing, and reduces adhesion of the circumcision site to diapers. This is the priority intervention to protect the surgical wound, per evidence-based circumcision care and infection control protocols in neonatal nursing practice.

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Correct Answer is B

Explanation

Choice A reason: Memory issues from TBI traumatic brain injury warrant cognitive assessment, not CAGE, which screens for alcoholism. Daily drinking suggests potential misuse, requiring CAGE. Memory affects recall, not alcohol screening priority, per substance abuse and neurological assessment standards in nursing admission interviews.

Choice B reason: Daily social drinking raises suspicion for alcohol misuse, warranting the CAGE questionnaire to screen for dependence. CAGE assesses alcohol-related behaviors, critical for identifying alcoholism in clients with regular intake, per substance abuse screening and admission assessment protocols in nursing practice.

Choice C reason: Antidepressant medication use suggests depression, requiring mental health assessment, not CAGE, which is for alcohol misuse. Daily drinking indicates screening need. Antidepressants are unrelated to alcohol patterns, per psychiatric and substance abuse assessment standards in nursing care during admission.

Choice D reason: Sexual assault history trauma requires trauma-informed care, not CAGE, which screens for alcoholism. Daily drinking triggers alcohol misuse screening. Assault history addresses psychological needs, per trauma assessment and substance abuse screening protocols, but CAGE is specific to alcohol in nursing.

A. Maintain client on strict bedrest. B. Limit fluid intake. C. Strain all urine. D. Login a high-calcium diet.

Correct Answer is C

Explanation

Choice A reason: Strict bedrest is not indicated for urolithiasis, as movement may aid stone passage by shifting ureteral dynamics. Severe flank pain from ureteral obstruction causes muscle spasms. Straining urine collects stones for analysis, identifying composition to guide treatment, making bedrest less critical than addressing the stone.

Choice B reason: Limiting fluid intake is contraindicated, as high fluids promote urine flow, aiding stone passage and diluting urinary solutes like calcium. Pain results from obstruction, and straining urine identifies stone type. Fluid restriction increases stone formation risk, making this harmful and counterproductive to urolithiasis management.

Choice C reason: Straining all urine collects stones for analysis, determining composition (e.g., calcium oxalate) to guide dietary and pharmacological prevention. Severe flank pain from ureteral obstruction highlights the need for stone identification. This addresses the pathophysiological cause, enabling tailored interventions to prevent recurrence and manage acute symptoms.

Choice D reason: A high-calcium diet is inappropriate, as most kidney stones are calcium-based. Dietary calcium moderation, based on stone analysis from straining urine, prevents recurrence. Pain management requires stone identification, not increased calcium intake, which could exacerbate stone formation, making this counterproductive for urolithiasis.

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The parents of a male infant newborn have signed an informed consent for circumcision. Which priority intervention should the nurse implement upon completion of the circumcision procedure?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which client information indicates the need for the nurse to use the CAGE questionnaire during the admission interview?

Correct Answer is B

Explanation

The nurse is caring for a client with urolithiasis who reports severe flank and abdominal pain. Which action should the nurse implement?

Correct Answer is C

Explanation

When advising a new mother in caring for a child with croup, which symptom should be a priority concern to the telephone triage nurse?

The nurse is assessing a client with a history of heart failure who reports new-onset dyspnea and fatigue. Which finding requires the most immediate intervention?

An older male client reports nocturia with difficulty starting his urine stream. Which additional assessment should the nurse perform to obtain further data related to this information?

The nurse is providing teaching to a client with type 2 diabetes mellitus about important points for disease and symptom management. Which statement by the client indicates understanding?

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Following admission for a cardiac catheterization, the nurse is providing discharge teaching to the parents of a 2-year-old toddler with Tetralogy of Fallot. Which instruction should the nurse give the parents if their child becomes pale, cool, and lethargic?