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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A: Partnering with a major pharmaceutical company to provide nebulizers at reduced cost to inner-city children is an example of a secondary prevention strategy aimed at managing asthma symptoms and exacerbations. It does not address primary prevention, which focuses on preventing the development of the condition in the first place.
Choice B: Offering free asthma screening to children at a health fair is a secondary prevention strategy aimed at early detection and management of existing asthma cases. It does not address primary prevention.
Choice C: Informing the city council of the need to strengthen the city's air pollution ordinances is a primary prevention strategy. It aims to address environmental factors (such as air pollution) that can contribute to the development of asthma in children. By reducing exposure to environmental triggers, the goal is to prevent new cases of asthma from occurring.
Choice D: Referring parents of preschoolers with asthma to a support group sponsored by the American Lung Association is a secondary prevention strategy aimed at providing support and education to
Correct Answer is C
Explanation
Choice A: A client receiving 30% oxygen via a non-rebreather face mask may be at risk for oxygen toxicity, but it does not necessarily indicate a higher risk of aspiration.
Choice B: A client with a nasogastric tube to low, intermittent suction may be at risk for aspiration if the tube is not functioning properly, but it does not represent the greatest risk compared to the other options.
Choice C: A client experiencing dysphagia who is prescribed a full liquid diet is at the greatest risk for aspiration. Dysphagia can lead to difficulty swallowing, increasing the risk of food or liquids entering the airway during swallowing.
Choice D: A client who has sensory aphasia and is receiving a clear liquid diet may have difficulty understanding or communicating about their dietary needs, but this does not necessarily indicate a higher risk of aspiration compared to a client with dysphagia.
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