A nurse is caring for a 2-month-old infant in a crib and needs the nasogastric tube on the counter near the sink. The nurse would now:.

Assess the infant's ability to roll over.

Put a nesting pillow around the infant.

Put the side rail all the way up.

Call for someone else to get the tube.

Answer and Explanation

The Correct Answer is D

Choice A rationale:

Assessing the infant's ability to roll over is unrelated to the situation. The nurse's focus should be on safely retrieving the nasogastric tube without leaving the infant alone.

Choice B rationale:

Using a nesting pillow is not appropriate in this scenario. The nurse should prioritize getting the nasogastric tube rather than introducing unnecessary items into the crib.

Choice C rationale:

Putting the side rail all the way up might hinder the nurse's ability to access the counter and the nasogastric tube. It is not the most effective action in this situation.

Choice D rationale:

Calling for assistance ensures that the infant's safety is maintained while the nurse retrieves the nasogastric tube. Leaving the infant unattended increases the risk of harm, so involving someone else is the appropriate action.

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Correct Answer is A

Explanation

Choice A rationale:

An increasing pulse rate suggests that the patient's condition is worsening. Tachycardia can indicate increased work of breathing and decreased oxygenation, which are concerning signs in laryngotracheobronchitis.

Choice B rationale:

Mouth breathing is a common response to airway obstruction, such as in laryngotracheobronchitis. While it indicates respiratory distress, it doesn't specifically suggest a worsening of the condition.

Choice C rationale:

An increase in nasal discharge might be seen with the common cold or other upper respiratory infections but is not a specific indicator of worsening laryngotracheobronchitis.

Choice D rationale:

A hoarse cry is a characteristic symptom of laryngotracheobronchitis due to inflammation of the airway. However, it is a common initial symptom and may not directly correlate with worsening of the condition.

A. "I will monitor the cast daily for foul odors.". B. "I will bring my child to the clinic for frequent checkups.". C. "I will use the cast stabilizing bar to turn my child.". D. "I will massage the skin around the edges of my child's cast.".

Correct Answer is C

Explanation

Choice A rationale:

Monitoring the cast daily for foul odors is a proper action to identify potential infection.

Choice B rationale:

Bringing the child for frequent checkups to the clinic is important to ensure the cast is healing properly.

Choice C rationale:

Using the cast stabilizing bar to turn the child can be concerning. There's no mention of a cast stabilizing bar, so this statement suggests a lack of understanding or misinformation.

Choice D rationale:

Massaging the skin around the edges of the child's cast can help prevent skin irritation, so it's an appropriate action.

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A nurse is caring for a 2-month-old infant in a crib and needs the nasogastric tube on the counter near the sink. The nurse would now:.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A patient is admitted from the emergency room with laryngotracheobronchitis. The patient has a brassy cough, stridor, and substernal retractions. The child is receiving an intravenous infusion and is placed in a mist tent. Which observation would indicate a worsening of the patient's condition?

Correct Answer is A

Explanation

A patient is to be discharged in a plaster spica cast. Which statement would indicate the need for further teaching with the patient's parent?

Correct Answer is C

Explanation

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