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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
b. Keep suction equipment at the client's bedside.
The nurse should plan to include keeping suction equipment at the client's bedside as an intervention for a client with Parkinson's disease. Parkinson's disease can cause dysphagia (difficulty swallowing) and an increased risk of aspiration. Having suction equipment readily available allows for prompt intervention in case of choking or aspiration episodes, ensuring the client's safety.
Explanation for the other options:
a. Restrict the client's fluid intake: Restricting the client's fluid intake is not typically indicated in the care of a client with Parkinson's disease. Adequate hydration is important for overall health and well-being. However, specific fluid restrictions may be necessary in certain situations, such as if the client has coexisting conditions like heart failure or kidney disease, which should be assessed and determined by the healthcare provider.
c. Instruct the client to look down when ambulating: In Parkinson's disease, individuals often experience a forward-flexed posture and a shuffling gait. Instructing the client to look down when ambulating is not an appropriate intervention. Instead, the nurse should encourage the client to maintain an upright posture, take smaller steps, and focus on taking deliberate and controlled movements to promote stability and reduce the risk of falls.
d. Position the client supine after eating: Positioning the client supine after eating is not recommended for a client with Parkinson's disease. This position can increase the risk of aspiration, as it may promote reflux and regurgitation of stomach contents. Instead, the nurse should advise the client to maintain an upright position, such as sitting in a chair or using a recliner with appropriate head support, to aid digestion and reduce the risk of aspiration.

Correct Answer is D
Explanation
The nurse should recognize that the client needs a referral for diabetic education when the client lists sweating, shaking, and palpitations as symptoms of hyperglycemia. These symptoms are actually associated with hypoglycemia, not hyperglycemia. Hyperglycemia is characterized by symptoms such as increased thirst, frequent urination, and fatigue.
Option a is incorrect because drawing up regular insulin before NPH when demonstrating injection technique is the correct procedure.
Option b is incorrect because seeing a primary care provider to treat corns on the feet is an appropriate action for a client with diabetes.
Option c is incorrect because treating hypoglycemic reactions with 15 g of carbohydrates is the recommended treatment.
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