The practical nurse (PN) is caring for a 3-month-old male infant two days after a pylorotomy and notices that the infant is restless, grimacing, and drawing his knees to his chest. What action should the PN implement?

Obtain blood glucose level.

Burp the infant every two-hours.

Wrap him with a warm blanket.

Give prescribed analgesic.

Answer and Explanation

The Correct Answer is D

Choice A: Obtaining a blood glucose level is not the most relevant intervention for an infant displaying signs of discomfort or pain, such as restlessness, grimacing, and drawing knees to the chest.

Choice B: Burping the infant every two hours is a routine care measure for infants but may not address the specific signs of discomfort described in this scenario.

Choice C: Wrapping the infant with a warm blanket may provide comfort but does not directly address the underlying issue of restlessness and discomfort.

Choice D: Giving the prescribed analgesic is the most appropriate action for addressing the infant's signs of distress, such as restlessness, grimacing, and drawing knees to the chest. These signs suggest the possibility of pain, and administering the prescribed pain medication can help alleviate the discomfort.

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Correct Answer is A

Explanation

Choice A: The nurse should determine the pH value of the aspirated fluid to confirm the placement of the NGT. Gastric aspirate typically has an acidic pH (usually below 5), which indicates that the tube is correctly placed in the stomach.

Choice B: Withdrawing the NGT and reinserting it is not necessary if the pH of the aspirate confirms gastric placement.

Choice C: Connecting the NGT to wall suction is not appropriate until placement has been confirmed with a pH test.

Choice D: Sending the fluid specimen to the lab is not the first step in verifying NGT placement. Checking the pH is a more immediate and reliable method.

A. Encourage the UAP to demonstrate the effective use of the incentive spirometer to the client. B. Schedule time later in the morning to review the use of the incentive spirometer with the client. C. Ask the practical nurse assigned to care for the client to review the use of the spirometer with the client. D. Advise the UAP that the respiratory therapist is responsible to supervise the client's use of the spirometer.

Correct Answer is C

Explanation

A. Encouraging the UAP to demonstrate the effective use of the incentive spirometer may not be appropriate since the UAP may not have the necessary training or expertise to provide proper instruction.
B. Scheduling time later to review the use of the spirometer does not address the immediate need for the client to understand how to use it effectively and may delay important interventions for respiratory health.
C. Asking the practical nurse assigned to care for the client to review the use of the spirometer ensures that the client receives accurate and professional guidance. The practical nurse has the training to properly instruct the client on the effective use of the incentive spirometer, which is crucial for preventing complications like atelectasis.
D. Advising the UAP that the respiratory therapist is responsible for supervising the client's use of the spirometer does not empower the UAP to take action and does not address the immediate concern regarding the client’s ineffective use.

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The practical nurse (PN) is caring for a 3-month-old male infant two days after a pylorotomy and notices that the infant is restless, grimacing, and drawing his knees to his chest. What action should the PN implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

While assessing placement of a nasogastric tube (NGT), the nurse aspirates cloudy green fluid into a syringe. Which intervention should the nurse Implement?

Correct Answer is A

Explanation

The unlicensed assistive personnel (UAP) who is caring for a postoperative client reports to the charge nurse that the client is not using the incentive spirometer effectively. What action should the charge nurse implement?

Correct Answer is C

Explanation

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