A nurse is caring for an infant in a provider's office.
Medical History Provider Visit #1. Heart rate 144/min.
Axillary temperature 39.7° C (103.5°F). Respiratory rate 32/min.
Oxygen saturation 95% on room air. Provider Visit #2 (4 days later).
Axillary temperature 37.4° C (99.3° F). Heart rate 132/min.
Respiratory rate 28/min.
Oxygen saturation 97% on room air.
Which of the following actions should the nurse plan to take? Select the actions the nurse should plan to take.
Teach caregivers to change diapers when wet.
Have caregivers administer 16 oz of water after each diarrhea stool.
Cleanse the diaper area with soap and water.
Collect nasal drainage for culture and sensitivity.
Teach caregivers to apply talcum powder to creases.
Use a nasal aspirator after feedings.
Correct Answer : A,G
A. Teach caregivers to change diapers when wet.
✅ Correct. Prevents skin breakdown and diaper dermatitis.
B. Have caregivers administer 16 oz of water after each diarrhea stool.
❌ Incorrect. Infants should not get plain water in such amounts. Risk of water intoxication & electrolyte imbalance. Oral rehydration solutions (ORS) or breast milk/formula are recommended instead.
C. Cleanse the diaper area with soap and water.
❌ Incorrect. Harsh soaps can irritate the skin. Best practice: gentle cleansing with warm water or mild wipes, and barrier ointment if needed.
D. Collect nasal drainage for culture and sensitivity.
❌ Incorrect. Only done if ordered and if infection is suspected. At follow-up (Visit #2), infant is afebrile and stable—no need for culture.
F. Teach caregivers to apply talcum powder to creases.
❌ Incorrect. Talcum powder is contraindicated in infants (risk of aspiration & respiratory issues). Barrier creams preferred.
G. Use a nasal aspirator after feedings.
✅ Correct. Safe and effective to clear nasal secretions and prevent aspiration or feeding difficulties.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
a.Talcum powder is not recommended for use with infants because it can be inhaled, potentially causing respiratory problems. Instead, a barrier cream or ointment (such as zinc oxide or petroleum jelly) should be used to protect the skin from moisture and irritants.
b.While cloth diapers can be less irritating than some disposable diapers, they may not be as effective at keeping the skin dry. The priority is to keep the area dry and clean, regardless of the type of diaper used. Super-absorbent disposable diapers are often recommended because they can help keep the skin dry.
c.Exposing the skin to hot air can cause burns and further irritation. Instead, allowing the skin to air dry naturally (without the use of hot air) during diaper changes can be beneficial.
d.A moisturizer creates a barrier between the skin and irritants like urine and stool.Wiping with a moisturizer can minimize friction during cleaning, which can be uncomfortable for the baby and further irritate the skin.Some moisturizers can help soothe and hydrate the inflamed skin, promoting healing.
Correct Answer is B
Explanation
A calcium level of 8.0 mg/dL is below the normal range for adults, which is 8.8 to 10.4 mg/dL.
This condition is known as hypocalcemia and can cause muscle spasms and aches.
Choice A is incorrect because a positive Chvostek’s sign, not a negative one, is a clinical sign of hypocalcemia.
Choice C is incorrect because dry, sticky mucous membranes are not a symptom of hypocalcemia.
Choice D is incorrect because polyuria (frequent urination) is a symptom of hypercalcemia (high calcium levels), not hypocalcemia.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.