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 A

Explanation

Choice A reason: A history of suicide attempts is crucial information when planning the care of a client using heroin because there is a high risk of further suicide attempts, especially in individuals with substance use disorders. The nurse must prioritize mental health safety and implement measures to monitor and support the client's psychological well-being to prevent any potential self-harm.

Choice B reason: While family history of schizophrenia is important, it is not immediately crucial to the plan of care for a client currently using heroin. This information is more relevant for long-term monitoring and psychiatric evaluation rather than immediate care planning.

Choice C reason: Undiagnosed social anxiety disorder (SAD) may contribute to substance use; however, it is not the most urgent concern in this scenario. The focus should be on immediate safety and stabilization, particularly addressing the high risk of suicide.

Choice D reason: Feelings of disorientation are significant but could be a result of heroin use. While important to assess, they are secondary to the immediate concern of preventing self-harm in a client with a history of suicide attempts.

A. Administer normal saline solution until Type AB negative is available. B. Obtain additional consent for administration of Type A negative blood. C. Recheck the client's hemoglobin, blood type, and Rh factor. D. Transfuse Type A negative blood until Type AB negative is available.

Correct Answer is D

Explanation

Choice A reason: Administering normal saline solution alone will not address the severe anemia caused by the low hemoglobin level.

Choice B reason: Obtaining additional consent is necessary, but it is not the immediate action required in this emergency situation.

Choice C reason: Rechecking the client's hemoglobin, blood type, and Rh factor is important, but the immediate priority is to address the severe anemia.

Choice D reason: Transfusing Type A negative blood is appropriate because it is compatible with AB negative blood and is necessary to treat the client's critical anemia.

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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

During an admission assessment, a client reports currently using heroin. Which information is most important for the nurse to consider in the plan of care?

Correct Answer is A

Explanation

Correct Answer is D

Explanation

Which assessment technique provides the most useful data when the nurse is concerned about possible urinary retention?

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