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 C

Explanation

Choice A: CPR is important but should be performed in conjunction with defibrillation. Since two defibrillation shocks have already been administered, the next step should be another shock.

Choice B : Obtaining an arterial blood gas sample is not the immediate priority when the client is in ventricular fibrillation. Defibrillation should be continued.

Choice C: Performing the third defibrillation shock is the next appropriate step in the advanced cardiac life support (ACLS) algorithm for ventricular fibrillation.

Choice D: Administering an IV bolus of epinephrine may be part of the ACLS protocol, but it is typically administered after defibrillation attempts.

A. I will withhold the antacid for now, and if you get indigestion, I will bring it back. B. CKD stresses your body to over-secrete gastric juices, and antacids help neutralize them. C. Your serum phosphate levels are up, and aluminum antacids prevent absorption of phosphates in foods. D. OK, I will let your healthcare provider know that you do not need the antacid.

Correct Answer is C

Explanation

Choice A: Withholding the antacid until the client gets indigestion is not appropriate because the primary purpose of aluminum hydroxide in CKD is to bind to phosphates in foods and reduce their absorption. It is not primarily used for indigestion.

Choice B: While CKD can lead to disturbances in gastric acid secretion, aluminum antacids are primarily used in CKD to control hyperphosphatemia by binding to phosphates in the gastrointestinal tract. Their role is not primarily related to gastric acid control.

Choice C: This response provides the most appropriate rationale. Aluminum antacids are often prescribed to CKD clients to prevent the absorption of dietary phosphates, which can contribute to hyperphosphatemia in CKD.

Choice D: Simply informing the healthcare provider that the client does not want to take the antacid is not the most informative response, as it does not address the rationale behind the medication use in CKD.

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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

Following two defibrillation shocks, the client's electrocardiogram (ECG) continues to indicate ventricular fibrillation (VF). Which intervention should the nurse implement next?

Correct Answer is C

Explanation

An adult male client with chronic kidney disease (CKD) is receiving aluminum hydroxide (Amphojel). He tells the nurse that since he does not have indigestion there is no need for him to take the antacid with his meals. Which response is best for the nurse to provide?

Correct Answer is C

Explanation

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