A nurse is assisting with the care of a 5-month-old infant who was just admitted to the pediatric unit.
For each potential provider's prescription, click to specify if the potential prescription is anticipated or contraindicated for the infant.
Maintain infant on continuous pulse oximetry.
Prepare the infant for a chest x-ray.
Initiate a peripheral IV line.
Maintain infant in supine position.
Offer small, frequent feedings.
Monitor intake and output.
The Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"A"},"F":{"answers":"A"}}
Continuous pulse oximetry: Anticipated because the infant has respiratory distress and requires continuous monitoring of oxygen saturation.
Chest x-ray: Anticipated to assess the extent of lung involvement due to the respiratory distress and wheezing noted.
Peripheral IV line: Anticipated since the peripheral line will be used to administer intravenous medications and fluids.
Supine position: Contraindicated because the infant prefers to sit upright and shows signs of respiratory distress, such as nasal flaring and retractions.
Small, frequent feedings: Anticipated to ensure adequate nutrition despite feeding difficulties.
Monitor intake and output: Anticipated to assess hydration status, especially since the infant has had decreased intake and output.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Mixing medication in a bottle of formula is not recommended as the infant may not finish the entire bottle, leading to incomplete dosage. It also changes the taste of the formula, which may cause feeding aversions.
B. Honey should not be given to infants under 1 year old due to the risk of botulism. It is not a suitable medium for mixing medication for young infants.
C. Placing the medication in an oral syringe allows for precise dosing and easy administration. It ensures that the infant receives the correct amount of medication.
D. Placing the medication in the back of the infant's throat using a dropper can cause gagging and aspiration. An oral syringe allows for better control and safer administration.
Correct Answer is C
Explanation
A. Instilling 2 mL of 0.9% sodium chloride is not recommended as it can cause discomfort and does not improve the effectiveness of suctioning.
B. Sterile technique, not clean technique, should be used when suctioning a tracheostomy to prevent infection.
C. Applying suction in 3 to 4 second increments is appropriate to clear the occlusion effectively without causing trauma to the trachea.
D. The catheter should not fit snugly into the tracheostomy tube; it should be small enough to fit comfortably to avoid trauma and ensure effective suctioning.
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