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 D
Explanation
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.
Correct Answer is B
Explanation
Choice A: Praising the client for weight loss without knowing the underlying cause may not be appropriate. Rapid and unexplained weight loss can be a sign of underlying health issues.
Choice B: Advising the client to schedule an appointment with a healthcare provider is the most appropriate action. Rapid and unexplained weight loss should be evaluated by a healthcare professional to identify any potential underlying health concerns.
Choice C: Advising the client to begin taking a multivitamin daily does not address the underlying cause of the weight loss and may not be the most appropriate action.
Choice D: Documenting the client's reason for using the herb is important but should be accompanied by further evaluation and intervention by a healthcare provider due to the significant weight loss.
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