The practical nurse (PN) is charting vital signs on a hand-writen flow sheet and realizes that an error has been made. What should the PN do to rectify this error?

The correct answer is choice C. Suction the oral and nasal passages.

Choice A rationale:

Turning the infant onto the right side may not be the most appropriate intervention for cyanosis caused by regurgitation. Cyanosis signifies a lack of oxygen, and simply changing the infant's position might not address the underlying issue.

Choice B rationale:

Giving oxygen by positive pressure is not the immediate intervention needed for regurgitation-induced cyanosis. While administering oxygen is important, the first step should involve clearing the airway to ensure proper oxygenation.

Choice C rationale:

Suctioning the oral and nasal passages is crucial in this situation as the cyanosis is likely due to the infant's airway being obstructed by regurgitated material. Clearing the airway can restore normal breathing and oxygenation.

Choice D rationale:

Stimulating the infant to cry is not the appropriate action when cyanosis is present. Cyanosis indicates a serious problem with oxygenation, and crying may worsen the situation by further compromising the infant's breathing.

The correct answer isChoice B.

Choice B rationale:

The practical nurse (PN) should instruct the unlicensed assistive personnel (UAP) to keep the client's skin clean and dry. Proper skin care is essential for a client with urinary and fecal incontinence to prevent the development of pressure ulcers. Keeping the skin clean and dry helps reduce moisture-related skin breakdown.

Choice A rationale:

Encouraging the client to rest quietly in bed is not directly related to preventing pressure ulcers. While adequate rest is essential for overall health, it does not specifically address the risk of pressure ulcers in an incontinent client.

Choice C rationale:

Obtaining supplies for contact precautions is unrelated to the client's risk of developing a sacral pressure ulcer. Contact precautions are used to prevent the spread of infectious diseases and do not address skin integrity.

Choice D rationale:

Documenting any changes in skin integrity is important, but it is the responsibility of the healthcare team, including the PN. However, this response does not provide proactive measures to prevent the pressure ulcer from occurring in the first place, which is the primary concern in this situation.