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 ["A","B","F"]
Explanation
Choice A: Confirming information from the solution label is essential to ensure that the correct parenteral nutrition solution is being administered.
Choice B: Confirming the healthcare provider's prescription is critical to verify the type, rate, and duration of the parenteral nutrition therapy, as well as any specific additives or electrolyte requirements.
Choice C: The medication administration record (MAR) is not directly related to parenteral nutrition, so it is not a primary source of information for this specific procedure.
Choice D: Measured residual volume is relevant for enteral nutrition administration but is not applicable to parenteral nutrition.
Choice E: The dietitian's progress notes may provide valuable information about the client's overall nutrition plan but are not the primary source for confirming the immediate administration of a specific parenteral nutrition solution.
Choice F: Confirming the client's identification band is essential to ensure the correct client receives the parenteral nutrition and to prevent errors in administration.
Correct Answer is D
Explanation
Choice A: Milk products, canned salmon, and fresh oysters are sources of calcium and may be included in the diet but are not primary sources of potassium.
Choice B: Cranberry juice, butter, and hard candy are not significant sources of potassium and may not address the client's hypokalemia.
Choice C: Hard cheese, whole-grain cereals, and dried vegetables are not primary sources of potassium and may not provide an adequate potassium intake.
Choice D: Potatoes, bananas, and oranges are all good dietary sources of potassium and should be encouraged for a client with hypokalemia. Increasing potassium-rich foods can help correct low potassium levels.
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