A nurse is providing teaching to the parents of a 1-week-old infant who has a prescription for home oxygen and pulse oximetry monitoring. Which of the following statements by the parents indicates a need for further teaching?

The pulse oximeter might not be accurate during times of excessive movement.

We will notify the doctor if the pulse oximeter consistently reads 100%.

We will rotate the probe of the pulse oximeter every 24 hours.

The probe of the pulse oximeter can be applied to a finger or a toe.

Answer and Explanation

The Correct Answer is C

Choice A reason: This statement is correct, as excessive movement can interfere with the accuracy of the pulse oximeter. The parents should ensure that the infant is calm and still when measuring the oxygen saturation.

Choice B reason: A pulse oximeter reading of 100% is not necessarily a cause for concern. In healthy individuals, a saturation level of 100% is achievable and does not require immediate notification to the doctor. It means that the infant's hemoglobin is fully saturated with oxygen, which is the goal of oxygen therapy. However, if you notice any issues or if the pulse oximeter consistently reads 100%, it would be a good idea to notify a healthcare professional.

Choice C reason: The probe placement does not need to be rotated every 24 hours. Once the probe is correctly positioned (usually on a finger or toe), it can remain in place for continuous monitoring without needing frequent adjustments.

Choice D reason: This statement is correct, as the probe of the pulse oximeter can be applied to a finger or a toe, depending on the size and fit of the probe. The parents should make sure that the probe is not too tight or loose, and that it does not interfere with the circulation of the extremity.

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Correct Answer is C

Explanation

Choice A reason: Absent bowel sounds are not a finding that indicates perforation of the appendix. Absent bowel sounds could be a sign of ileus, obstruction, or peritonitis, but they are not specific to appendicitis.

Choice B reason: Low-grade fever is not a finding that indicates perforation of the appendix. Low-grade fever could be a sign of infection, inflammation, or dehydration, but it is not specific to appendicitis.

Choice C reason: Sudden decrease in abdominal pain is a finding that indicates perforation of the appendix. Sudden decrease in abdominal pain means that the pressure inside the appendix has been released, causing the appendix to rupture and spill its contents into the peritoneal cavity. This can lead to severe complications such as sepsis, abscess, or shock.

Choice D reason: Flaccid abdomen is not a finding that indicates perforation of the appendix. Flaccid abdomen could be a sign of muscle relaxation, sedation, or paralysis, but it is not specific to appendicitis.

A. Obtain blood culture specimens. B. Administer an antipyretic. C. Prepare for nasotracheal intubation. D. Insert an IV catheter.

Correct Answer is C

Explanation

Choice A reason: Obtaining blood culture specimens is important to identify the causative organism and guide antibiotic therapy, but it is not the priority action for a child who is in respiratory distress. The nurse should first secure the airway and stabilize the child's condition.

Choice B reason: Administering an antipyretic may help lower the fever and reduce discomfort, but it does not address the cause of the dyspnea and drooling, which may indicate epiglottitis. This is a life-threatening condition that requires immediate airway management.

Choice C reason: Preparing for nasotracheal intubation is the priority action for a child who has signs of epiglottitis, as it can prevent airway obstruction and respiratory failure. The nurse should have the equipment and personnel ready for intubation and avoid any stimulation or manipulation of the throat that can trigger laryngeal spasm.

Choice D reason: Inserting an IV catheter is necessary to administer fluids and medications, but it is not the first priority for a child who is in respiratory distress. The nurse should focus on the airway before the circulation.

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A nurse is providing teaching to the parents of a 1-week-old infant who has a prescription for home oxygen and pulse oximetry monitoring. Which of the following statements by the parents indicates a need for further teaching?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a child who is admitted with suspected acute appendicitis. Which of the following findings should alert the nurse to perforation of the child's appendix?

Correct Answer is C

Explanation

A nurse in an emergency department is assessing a 2-year-old child who has a high fever, severe dyspnea, and is drooling. Which of the following actions is the nurse's priority?

Correct Answer is C

Explanation

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