A 10-month-old infant who has had a cleft palate repair returns to the nursing unit from surgery. Which of the following nursing actions demonstrates the most important priority for airway care?
Suctions mouth and nasopharyngeal passages.
Gives IV morphine for pain.
Cleans suture line with normal saline.
Elevates the head of the bed 30 degrees.
The Correct Answer is A
Choice A reason: This statement is correct, as suctioning the mouth and nasopharyngeal passages is the most important priority for airway care in an infant who has had a cleft palate repair. The nurse should suction the infant frequently and gently to remove any blood, mucus, or secretions that may obstruct the airway or cause aspiration. The nurse should also monitor the infant's respiratory rate, oxygen saturation, and signs of distress.
Choice B reason: This statement is incorrect, as giving IV morphine for pain is not the most important priority for airway care in an infant who has had a cleft palate repair. Although pain management is essential for the infant's comfort and recovery, it is not the first intervention for airway care. The nurse should assess the infant's pain level and administer the prescribed analgesics as needed, but only after ensuring the airway is clear and patent.
Choice C reason: This statement is incorrect, as cleaning the suture line with normal saline is not the most important priority for airway care in an infant who has had a cleft palate repair. Although wound care is important for the prevention of infection and the promotion of healing, it is not the first intervention for airway care. The nurse should clean the suture line with sterile saline or water as ordered, and avoid using cotton swabs or hydrogen peroxide that may damage the tissue or cause bleeding.
Choice D reason: This statement is incorrect, as elevating the head of the bed 30 degrees is not the most important priority for airway care in an infant who has had a cleft palate repair. Although elevating the head of the bed can help reduce the swelling and improve the drainage, it is not the first intervention for airway care. The nurse should position the infant on the side or abdomen, with the head slightly elevated, and avoid placing the infant on the back or putting pressure on the operative site.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: This statement is false, as a sense of hopelessness and despair are not a normal part of adolescence, but signs of depression and suicidal ideation. The nurse should educate the adolescents and their parents about the warning signs of suicide and the importance of seeking professional help.
Choice B reason: This statement is false, as previous suicide attempts are a major risk factor for completed suicides. The nurse should assess the adolescents for any history of self-harm or suicide attempts and provide them with appropriate interventions and referrals.
Choice C reason: This statement is true, as LGBT adolescents are at a particularly high risk for suicide due to the stigma, discrimination, and bullying they may face from their peers, family, and society. The nurse should provide a safe and supportive environment for the LGBT adolescents and connect them with resources and support groups.
Choice D reason: This statement is false, as problem-solving skills are of great value to the suicidal adolescent. The nurse should teach the adolescents how to cope with stress, deal with conflicts, and seek help when needed. The nurse should also help the adolescents develop positive self-esteem and resilience.
Correct Answer is D
Explanation
Choice A reason: Somnolence, hypotension, and oliguria are signs of decompensated shock, which occurs when the body's compensatory mechanisms fail to maintain adequate tissue perfusion.
Choice B reason: Irritability, tachypnea, and hypotension are also signs of decompensated shock, as the respiratory rate increases to compensate for the low blood pressure and oxygen delivery.
Choice C reason: Irritability, capillary refill time > 2 seconds, and bradycardia are not typical signs of compensated shock, as the heart rate usually increases to maintain cardiac output and blood pressure.
Choice D reason: Irritability, tachycardia, and poor peripheral perfusion are signs of compensated shock, which occurs when the body tries to maintain adequate tissue perfusion by increasing the heart rate, constricting the peripheral blood vessels, and shunting blood to the vital organs.
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