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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Free Nursing Study Resources

Correct Answer is A

Explanation

A. Muscle pain can be a sign of rhabdomyolysis, a serious side effect of lovastatin that requires immediate evaluation and intervention.

B. Altered taste is a less serious side effect and does not require urgent follow-up.

C. Diarrhea and flatulence are common and less urgent side effects of lovastatin.

D. Abdominal cramps are uncomfortable but less critical compared to muscle pain associated with potential rhabdomyolysis.

Correct Answer is []

Explanation

Alcohol withdrawal syndrome often presents with symptoms such as tremors, palpitations, and agitation, and can escalate to severe symptoms including hallucinations and seizures.

Assessing for hallucinations is important because it helps in identifying more severe withdrawal symptoms that may require intervention.

Implementing seizure precautions is critical as withdrawal seizures can be life-threatening.

Monitoring pulse and blood pressure helps evaluate the client’s physiological response to withdrawal and the effectiveness of interventions.

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Naxlex Comprehensive Predictor Exams

Which problem reported by a client taking lovastatin requires the most immediate follow-up by the nurse?

Correct Answer is A

Explanation

Patient Data Exhibits Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.

Correct Answer is []

Explanation

A client with heart failure (HF) develops cardiac tamponade. The client has muffled, distant heart sounds, and is anxious and restless. After Initiating oxygen therapy and IV hydration, which intervention is most important for the nurse to implement?

Exhibits The nurse reviews the healthcare provider's orders. Select the 4 things the nurse should educate the client about taking his medication.

An unlicensed assistive personnel (UAP) leaves the unit without notifying the staff. In which order should the unit manager implement these interventions to address the UAP's behavior? (Place the actions in order from first on top to last on bottom.)

An older client with osteoarthritis reports increasing pain and stiffness in the right knee and asks how to reduce these symptoms. In responding to the client, the nurse recognizes what pathology as the cause of the symptoms?

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

A client is being treated for syndrome of inappropriate antidiuretic hormone (SIADH). On examination, the client has a weight gain of 4.4 lbs (2 kg) in 24 hours and an elevated blood pressure. Which intervention should the nurse implement first?