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 D

Explanation

Choice A rationale:

The patient ties his shoelaces. This choice is incorrect as most 3-year-olds lack the fine motor skills required to tie shoelaces independently.

Choice B rationale:

The patient gives his first and last name. This choice is also incorrect, as most 3-year-olds might not have developed language skills to provide their full name accurately.

Choice C rationale:

The patient can tell time. This choice is unrealistic for a 3-year-old, as telling time involves cognitive and conceptual abilities that are not yet developed at this age.

Choice D rationale:

The patient draws a stick figure with six parts. This choice is correct. Around age 3, children usually start drawing simple figures with a head, arms, legs, and possibly facial features, totaling around six parts. This reflects appropriate developmental milestones for a child of this age.

A. The patient's stool is normal. B. The patient's sclerae are white. C. The patient's buccal mucosa is moist. D. The patient's urine is negative for glucose. I. If the pancreatic enzymes are having the desired effect for a patient with cystic fibrosis, the nurse should expect to make which observation?

Correct Answer is A

Explanation

Choice A rationale:

If the pancreatic enzymes are effectively aiding in digestion for a patient with cystic fibrosis, the expected outcome would be improved absorption of nutrients and fats. This would result in normal stool consistency and color. Cystic fibrosis often impairs the pancreas' ability to produce sufficient digestive enzymes, leading to malabsorption and fatty stools. Therefore, observing normal stool consistency indicates that the enzymes are working adequately.

Choice B rationale:

The color of the patient's sclerae (the white part of the eyes) is not directly related to the effectiveness of pancreatic enzymes in cystic fibrosis. Scleral color can be affected by various factors such as jaundice, liver function, and blood disorders.

Choice C rationale:

Moist buccal mucosa (inner lining of the mouth) is not a specific indicator of the effectiveness of pancreatic enzymes. This observation could be influenced by hydration status and overall oral care.

Choice D rationale:

Glucose presence in urine is more related to diabetes management rather than the effects of pancreatic enzymes in cystic fibrosis. The absence of glucose in urine does not provide information about the efficacy of these enzymes.

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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 nurse is caring for a 3-year-old patient. Which behavior is developmentally appropriate for this patient?

Correct Answer is D

Explanation

If the pancreatic enzymes are having the desired effect for a patient with cystic fibrosis, the nurse should expect to make which observation?

Correct Answer is A

Explanation

For which clients would the varicella (chickenpox) vaccine be contraindicated? Select all that apply.

A 3-week-old patient is hospitalized for surgical repair of hypertrophic pyloric stenosis. On the third postoperative day, the mother expresses concern that her infant vomited approximately one-fourth of his feeding. Which response by the nurse would be most appropriate at this time?

A nurse is caring for a pediatric client who is receiving pancreatic enzyme replacement therapy. Which nursing action measures the effectiveness of the therapy?

After a cleft lip repair, a child is receiving formula feedings through a syringe. The child's parent is participating in care. Which of these actions by the parent indicates a need for further instructions about feeding the child? The caregiver:.

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?

A nurse discusses poison prevention with a caregiver of a 2 1/2-year-old child. Which statement by this caregiver indicates a need for further education?

The nurse is providing discharge instructions to the parent of a patient who had a tonsillectomy/adenoidectomy. Which statement would indicate that the parent needs further teaching?

A 13-year-old with severe scoliosis is admitted for insertion of Harrington rods. In preparing the patient for postoperative care, the nurse should provide which information?