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 ["B","C","D"]

Explanation

Choice A: Closing the blinds to darken the room may not be the immediate priority during a seizure. Ensuring the safety and well-being of the child takes precedence.

Choice B: Asking the mother to release the child is an important action. It is essential to prevent any further physical restraint during a seizure, as it can cause harm to the child or the person attempting to restrain them.

Choice C: Monitoring the child's airway and tongue is crucial during a seizure to prevent any obstruction that could interfere with breathing. It is important to ensure the child does not choke on saliva or vomit.

Choice D: Administering an anticonvulsant medication may be necessary in certain situations, especially if the seizure persists or is prolonged. The healthcare provider's orders should be followed for the administration of appropriate medications

Choice E: Placing pillows inside the side rails is not a relevant intervention during a seizure. The focus should be on ensuring the child's safety, assessing their airway, and providing appropriate care during the seizure.

A. An older female client who had a hip replacement yesterday and is notably pale with a Hemoglobin of 10.5 g/dl. B. An adult client with osteomyelitis of the ankle who refuses an IV restart that is needed to administer antibiotics. C. An elderly client with low back pain who removed the pelvic traction and repeatedly states a strong desire to go home. D. A young adult client with a closed reduction of a fractured femur who has been complaining of increasingly severe pain.

Correct Answer is D

Explanation

Choice A: The older female client who had a hip replacement yesterday and is notably pale with a hemoglobin of 10.5 g/dl likely needs attention, but the information provided does not indicate an urgent, life-threatening situation. Immediate intervention may not be necessary based on the information given.

Choice B: The adult client with osteomyelitis of the ankle who refuses an IV restart for antibiotics is concerning, but it does not represent an immediate life- threatening situation. The client's refusal should be addressed, but it may not require immediate attention.

Choice C: The elderly client with low back pain who removed pelvic traction and wants to go home may require assessment and intervention, but the information provided does not indicate an urgent, life-threatening situation. It may not be the first priority.

Choice D: The young adult client with a closed reduction of a fractured femur complaining of increasingly severe pain is the most concerning. Pain assessment and management are critical, and uncontrolled pain can lead to complications. This client should be attended to first to assess and address the pain.

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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

A male child is being prepared for a computed tomography (CT) scan when he begins to have a tonic clonic seizure. His mother is hysterical and is trying to hold the child down. Which action(s) should the nurse take? (Select all that apply.)

Correct Answer is ["B","C","D"]

Explanation

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Correct Answer is D

Explanation

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