A nurse is contributing to the plan of care for a 12-month-old infant following cleft palate repair. Which of the following actions should the nurse include?
Allow the infant to have soft foods.
Maintain elbow restraints on the infant.
Instruct the parents to feed the infant with a spoon.
Tell the parents to avoid brushing the infant's teeth for two weeks.
The Correct Answer is B
The nurse should include maintaining elbow restraints on the infant in the plan of care following cleft palate repair. This helps to prevent the infant from touching their surgical site and disrupting the healing process.
a) Allowing the infant to have soft foods may be appropriate, but it is not the highest priority. The infant's diet should be determined by the provider and based on the infant's individual needs.
c) Instructing the parents to feed the infant with a spoon may be appropriate, but it is not the highest priority. The infant's feeding method should be determined by the provider and based on the infant's individual needs.
d) Telling the parents to avoid brushing the infant's teeth for two weeks may be appropriate, but it is not the highest priority. The infant's oral care should be determined by the provider and based on the infant's individual needs.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A nurse collecting data from a client who reports having diarrhea for the past 3 days should identify that muscle weakness is a symptom of hypokalemia. Hypokalemia is a condition in which the blood potassium level is low and can be caused by excessive fluid loss through diarrhea. Potassium helps regulate muscle contractions, so when blood potassium levels are low, muscles may produce weaker contractions which result in muscle weakness.
The other options are not typical symptoms of hypokalemia.
a) Pitting edema is not a typical symptom of hypokalemia.
b) Diplopia is not a typical symptom of hypokalemia.
d) Hyperactive bowel sounds are not a typical symptom of hypokalemia.
Correct Answer is A
Explanation
After the nurse administers a PRN pain medication to a client, the nurse can assign the assistive personnel (AP) to document the client's respiratory rate in 1 hour. This is within the scope of practice of an AP.
The other tasks are not appropriate for an AP to perform.
Monitoring the client for an allergic reactionand evaluating the client for therapeutic effects are both nursing assessments that should be performed by the nurse.
Checking the client's response to the medication is also a nursing assessment that should be performed by the nurse.
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