While caring for a toddler receiving oxygen via face mask, the nurse observes that the child's lips and nares are dry and cracked. Which intervention should the nurse implement?

Apply petroleum jelly to the child's nose and lips.

Use a topical lidocaine analgesic for cracked lips.

Ask the mother what she usually uses on the child's lips and nose.

Use a water soluble lubricant on affected oral and nasal mucosa.

Answer and Explanation

The Correct Answer is D

Choice A reason: Applying petroleum jelly is not recommended because it is not water-soluble and can potentially be inhaled into the lungs, posing a risk.

Choice B reason: Using a topical lidocaine analgesic is not suitable for cracked lips and nares, as it is intended for pain relief rather than moisturizing.

Choice C reason: Asking the mother what she usually uses on the child's lips and nose is helpful for gathering information but does not provide an immediate intervention.

Choice D reason: Using a water soluble lubricant is appropriate because it helps to moisturize the dry and cracked areas without posing a risk of inhalation, ensuring the child's comfort and safety.

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Correct Answer is D

Explanation

Choice A reason: Turning every 2 hours is important for preventing pressure ulcers but is not the primary concern for a client with severe ulcerative colitis and recent surgery.

Choice B reason: Recording wound drainage is necessary but not the most critical intervention compared to fluid balance.

Choice C reason: Assessing skin condition is important but secondary to maintaining fluid balance in a critically ill client.

Choice D reason: Replacing fluids based on intake and output is crucial to manage dehydration and electrolyte imbalances, which are common in clients with severe ulcerative colitis.

A. Oral medications, including analgesics, are tolerated without vomiting. B. Vital signs within normal limits and blood pressure of 142/94 mm Hg. C. Pain rating of 5 on a 0 to 10 scale and taking oral analgesics every 4 hours. D. Client is able to ambulate to the bathroom safely to void. E. Bowel sounds are present in all four quadrants and abdomen is soft.

Correct Answer is ["A","D"]

Explanation

Choice A reason: Tolerating oral medications without vomiting is essential for discharge to ensure the client can manage pain and take necessary medications at home.

Choice B reason: While vital signs are important, the slightly elevated blood pressure alone may not prevent discharge if other criteria are met.

Choice C reason: A pain rating of 5 managed with oral analgesics is acceptable for discharge if the client can manage pain at home.

Choice D reason: Being able to ambulate to the bathroom safely is crucial for discharge to ensure the client can independently manage basic needs.

Choice E reason: Bowel sounds and a soft abdomen are important but are not the primary criteria for discharge in this context.

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While caring for a toddler receiving oxygen via face mask, the nurse observes that the child's lips and nares are dry and cracked. Which intervention should the nurse implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with a history of inflammatory bowel disease develops severe ulcerative colitis and is admitted to the intensive care unit after surgery for a fistula repair. Which intervention is most important for the nurse to include in the plan of care?

Correct Answer is D

Explanation

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Correct Answer is ["A","D"]

Explanation

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