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 C
Explanation
The correct answer ischoice C.
Choice A rationale:
A lead level of 10 mcg/dL is above the CDC’s reference value of 3.5 mcg/dL and would require more immediate follow-up and intervention, not just rescreening in one year.
Choice B rationale:
A lead level of 18 mcg/dL is significantly elevated and would necessitate immediate medical intervention and frequent monitoring, rather than waiting a year for rescreening.
Choice C rationale:
A lead level of 4 mcg/dL is slightly above the CDC’s reference value of 3.5 mcg/dL.While it is concerning, it may be appropriate to rescreen in one year if no other risk factors are present.
Choice D rationale:
A lead level of 44 mcg/dL is dangerously high and requires urgent medical treatment and frequent follow-up, not just rescreening in one year.
Correct Answer is D
Explanation
Individuals with spina bifida who are paralyzed from the waist down may have difficulty emptying their bladder completely and may need to perform intermittent catheterization.
The frequency of catheterization can vary depending on the individual’s needs, but it is typically performed every 3-6 hours or 4-6 times per day.
Choice A, “I do wheelchair exercises while watching TV,” is a positive statement because exercise is important for overall health and well-being.
Choice B, “I carry a water bottle with me because I drink a lot of water,” is also a positive statement because staying hydrated is important for overall health.
Choice C, “I use a suppository every night to have a bowel movement,” is not necessarily an indication for further teaching because some individuals with spinal bifida may need to use bowel management techniques such as suppositories to help regulate bowel movements.
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