A 2-month-old infant with hypertrophic pyloric stenosis is receiving parenteral fluids for rehydration and decompression of the stomach while waiting for surgical repair. To maintain normal growth and development of the child during this period, which action should the nurse include in the plan of care?

Ensure placement of the nasogastric tube with an abdominal x-ray.

Use sterile water for gastric lavage.

Offer a pacifier for non-nutritive sucking.

Speak to the healthcare provider about instituting physical therapy.

Answer and Explanation

The Correct Answer is C

A. Ensuring the correct placement of the nasogastric tube with an abdominal x-ray is important for treatment but does not address the infant's developmental needs.

B. Using sterile water for gastric lavage may be necessary for stomach decompression but does not directly support the infant's growth and development.

C. Offering a pacifier for non-nutritive sucking provides comfort and helps maintain the infant’s sucking reflex, which is crucial for feeding and oral development.

D. Physical therapy is not relevant for a 2-month-old infant with hypertrophic pyloric stenosis and does not address immediate developmental needs.

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

Explanation

A. Auscultating bowel sounds in all quadrants helps assess the extent of gastrointestinal involvement and possible complications.

B. Administering warfarin is not appropriate in this acute situation where there may be active bleeding; instead, the heparin infusion should be stopped.

C. Assessing the characteristics of the pain is crucial for determining the severity and possible source of the gastrointestinal symptoms.

D. Monitoring stools for the presence of blood is essential to confirm gastrointestinal bleeding and the extent of blood loss.

E. Reviewing the last partial thromboplastin time results helps assess the anticoagulation status of the client and the potential need for reversal.

Correct Answer is ["41.7"]

Explanation

Step 1: Convert grams to milligrams

The prescribed dose is 5 grams (g) daily.

1 gram (g) = 1,000 milligrams (mg)
5 g = 5,000 mg daily

Step 2: Determine the dose per administration

The medication is to be given every 8 hours, meaning the total daily dose is divided into three equal doses:

5,000mg/3=1,666.67mgperdose

Step 3: Use the medication concentration to find the volume

The available suspension is 200 mg per 5 mL. Using the ratio formula:

200mg/5mL=1,666.67mg/XmL

Solve for X:

X=1,666.67×5/200

X=8,333.35/200=41.67mL

Answer: 41.7 mL (Rounded off to the nearest tenth)

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Naxlex Comprehensive Predictor Exams

A client with deep vein thrombosis (DVT) is receiving a continuous intravenous heparin infusion. The client now has tarry, black diarrhea and reports abdominal pain. Which actions should the nurse implement? Select all that apply.

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

Explanation

Correct Answer is ["41.7"]

Explanation

Step 1: Convert grams to milligrams

Step 2: Determine the dose per administration

Step 3: Use the medication concentration to find the volume

Answer: 41.7 mL (Rounded off to the nearest tenth)

While preparing a client's routine 0800 medications, the nurse opens the medication packaging and discards in the trash prior to scanning the barcode label. Which action should the nurse implement?

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After a scheduled downtime, the computer documentation system fails to restart. Which action should the nurse take first?

After receiving a change of shift report for clients on a medical surgical unit, which task should the nurse assign to an unlicensed assistive personnel (UAP)?

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The nursing staff on a medical unit includes a registered nurse (RN), practical nurse (PN), and an unlicensed assistive personnel (UAP). Which task should the charge nurse assign to the RN?

The nurse is interviewing a client with schizophrenia. Which client behavior requires immediate intervention?

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