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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Hypercalcemia refers to high calcium levels in the blood, and it is not a common complication associated with furosemide use. Furosemide primarily affects electrolytes like potassium.
Choice B rationale:
Furosemide is a loop diuretic that can lead to excessive potassium loss through urine, potentially causing hypokalemia (low potassium levels). Monitoring potassium is crucial to prevent complications like muscle weakness and cardiac arrhythmias.
Choice C rationale:
Hypocalcemia, which is low calcium levels, is not a typical complication of furosemide use. Furosemide's primary impact is on sodium and potassium balance.
Choice D rationale:
Hyperkalemia is the opposite of what furosemide commonly causes. Furosemide-induced diuresis often leads to hypokalemia, not hyperkalemia.
Correct Answer is A
Explanation
Choice A rationale:
Stomatitis, inflammation of the oral mucosa, can make eating painful, leading to inadequate nutritional intake. The discomfort caused by stomatitis can discourage the patient from eating, potentially resulting in malnutrition. Ensuring adequate nutritional intake is crucial to support the patient's immune system and healing during antineoplastic therapy.
Choice B rationale:
Dental caries are not directly related to stomatitis. Stomatitis is inflammation of the oral mucosa, whereas dental caries involve decay of tooth structure due to bacterial action on food debris and sugars.
Choice C rationale:
Diarrhea is unrelated to stomatitis. Diarrhea involves frequent, loose, or watery stools, often caused by gastrointestinal infections, certain medications, or dietary intolerances.
Choice D rationale:
Gingival hyperplasia is an overgrowth of gum tissue and is not a likely result of stomatitis. It can be associated with some medications like anticonvulsants.
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