A charge nurse is planning care for an infant who has failure to thrive. Which of the following actions should the nurse include in the plan of care?

Give the infant fruit juice between feedings.

Use half-strength formula when feeding the infant.

Assign consistent nursing staff to care for the infant.

Keep the infant in a visually stimulating environment.

Answer and Explanation

The Correct Answer is C

Consistent care from the same nursing staff can help establish a routine and build trust between the infant and caregivers.

Choice A is wrong because giving an infant fruit juice between feedings does not address the underlying causes of failure to thrive.

Choice B is wrong because using half-strength formula when feeding the infant can exacerbate the problem by providing insufficient nutrition.

Choice D is wrong because keeping the infant in a visually stimulating environment does not address the underlying causes of failure to thrive.

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Correct Answer is C

Explanation

A potassium level of.2 mEq/L is considered low.

Low potassium levels can cause muscle weakness and spasms.

Hyporeflexia refers to below normal or absent reflexes and can be a sign of muscle weakness.

Choice A is wrong because oliguria, or decreased urine output, is not a common symptom of low potassium levels.

Choice B is wrong because hypertension, or high blood pressure, is not a common symptom of low potassium levels.

Choice D is wrong because hyperactive bowel sounds are not a common symptom of low potassium levels.

A. A toddler who has nephrotic syndrome and facial edema. B. An adolescent who has Crohn's disease and a recent weight loss of 5 kg (11 lb). C. A preschool-age child who has a muffled voice and no spontaneous cough. D. A school-age child who has diabetes mellitus and a blood glucose of 200 mg/dL.

Correct Answer is C

Explanation

A preschool-age child who has a muffled voice and no spontaneous cough should be assessed first.

These symptoms may indicate epiglottitis, which is a life-threatening condition that requires immediate medical attention.

Choice A, B and D are also important but not as urgent as choice C. A toddler with nephrotic syndrome and facial edema, an adolescent with Crohn’s disease and recent weight loss, and a school-age child with diabetes mellitus and a blood glucose of 200 mg/dL should be assessed after the preschool-age child with a muffled voice and no spontaneous cough.

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A charge nurse is planning care for an infant who has failure to thrive. Which of the following actions should the nurse include in the plan of care?

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Naxlex Comprehensive Predictor Exams

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