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 D

Explanation

Choice A reason: Discontinuing the nasal cannula is inappropriate, as 94% SpO₂ indicates mild hypoxemia from pneumonia, requiring oxygen to support alveolar diffusion. The rash likely results from cannula pressure, not oxygen delivery. Padding addresses the rash without compromising respiratory support, ensuring continued therapy.

Choice B reason: Decreasing to 1 L/minute may worsen hypoxemia in pneumonia, where inflamed alveoli impair gas exchange (SpO₂ 94%). The rash is from mechanical irritation, not flow rate. Padding relieves pressure, maintaining oxygen delivery to improve saturation, making flow reduction counterproductive to respiratory needs.

Choice C reason: Applying lubricant reduces friction but not pressure causing the red macular rash from prolonged cannula contact. Lubricants risk aspiration. Padding alleviates pressure points, preventing skin breakdown while maintaining oxygen for pneumonia, addressing the rash’s mechanical cause more effectively than lubrication.

Choice D reason: Placing padding around the cannula tubing relieves pressure on the cheek, preventing skin breakdown from the red macular rash. This maintains oxygen at 3 L/minute, critical for pneumonia’s hypoxemia, where inflamed alveoli reduce oxygen diffusion. Padding ensures skin integrity and respiratory support, addressing both issues effectively.

A. Serum potassium and skin turgor. B. Eosinophil count and constipation. C. Blood pressure and risk for falls. D. Heart rate and reports of nausea.

Correct Answer is C

Explanation

Choice A reason: Monitoring serum potassium is relevant, as lisinopril can cause hyperkalemia by reducing aldosterone, impairing potassium excretion. Skin turgor, however, assesses hydration, not ACE inhibitor effects. Blood pressure monitoring is more critical, as lisinopril lowers blood pressure via vasodilation, risking hypotension and falls, especially in elderly clients.

Choice B reason: Eosinophil count and constipation are unrelated to lisinopril’s effects. Elevated eosinophils may suggest allergies, but this is rare with ACE inhibitors. Constipation is not a common side effect. Lisinopril’s primary action is renin-angiotensin inhibition, making blood pressure and fall risk monitoring more urgent to prevent hypotensive complications.

Choice C reason: Lisinopril reduces angiotensin II, promoting vasodilation and lowering blood pressure. Monitoring blood pressure detects hypotension, which increases fall risk, particularly in older adults, due to dizziness or orthostatic changes. This directly assesses the drug’s cardiovascular effects, ensuring safety by preventing falls or syncope, making it the priority assessment.

Choice D reason: Heart rate and nausea are not primary lisinopril concerns. Tachycardia may occur secondary to hypotension, and nausea is rare. The drug’s main effect is blood pressure reduction via ACE inhibition, necessitating monitoring for hypotension and fall risk to ensure patient safety, as these are more immediate and significant pharmacological effects.

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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

After obtaining an oxygen saturation level of 94% for a client with pneumonia who is receiving oxygen per nasal cannula at 3 L/minute, the nurse observes a red macular rash developing on the client’s right cheek. Which intervention should the nurse implement?

Correct Answer is D

Explanation

After administering lisinopril, an angiotensin-converting enzyme (ACE) inhibitor, it is most important for the nurse to monitor which assessment finding?

Correct Answer is C

Explanation

Which action should the nurse implement when inserting an indwelling catheter for an uncircumcised male client?

At 0800, the practical nurse (PN) reports to the registered nurse (RN) that a client’s blood pressure is 140/90 mm Hg. When the RN arrives to administer the 0900 antihypertensive medication, the client is oriented but lethargic, pale, and diaphoretic. Which action should the RN implement first?

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