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. Residual fluid should not be discarded unless instructed by a healthcare provider, as it provides important information about gastric emptying and tolerance to previous feedings.
B. Formula should be brought to room temperature before administration to avoid causing discomfort or gastric irritation. Cold formula can cause cramps and slow gastric motility.
C. Elevating the head of the bed to a 45-degree angle helps prevent aspiration during feeding and promotes proper digestion. This position is critical for patient safety.
D. The feeding rate should be individualized based on the child's tolerance and prescribed regimen, and 30 mL/min is typically too fast for a preschooler, increasing the risk of aspiration or intolerance.
Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"C"}
Explanation
The nurse should clarify the child's prescription of dextrose 5% in 0.45% sodium chloride with 20 mEq potassium chloride/L at 75 mL/hr because of the child's laboratory values. The elevated potassium level of 6.2 mEq/L, which is above the normal range of 3.4 to 4.7 mEq/L, indicates hyperkalemia. Administering additional potassium could exacerbate this condition, therefore, it is crucial to review the prescription and adjust it accordingly to ensure the safety and well-being of the child.
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