A nurse is providing teaching to the parents of a 6-month-old infant who is beginning to eat solid foods. The nurse should identify which of the following findings as an indication of an allergic reaction?
Fever
Jaundice
Bruising
Diarrhea
The Correct Answer is D
Choice A reason: Fever is not an indication of an allergic reaction, as it is a sign of infection or inflammation. The nurse should assess the infant for other causes of fever, such as ear infection, urinary tract infection, or viral illness.
Choice B reason: Jaundice is not an indication of an allergic reaction, as it is a sign of liver dysfunction or hemolysis. The nurse should evaluate the infant for other causes of jaundice, such as hepatitis, biliary atresia, or hemolytic anemia.
Choice C reason: Bruising is not an indication of an allergic reaction, as it is a sign of trauma or bleeding disorder. The nurse should examine the infant for other causes of bruising, such as injury, coagulopathy, or leukemia.
Choice D reason: Diarrhea is an indication of an allergic reaction, as it is a sign of gastrointestinal hypersensitivity or intolerance. The nurse should ask the parents about the infant's food intake, history of allergies, and symptoms of anaphylaxis, such as hives, swelling, or difficulty breathing.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Measuring the client's gastric residual every 12 hr is not frequent enough to monitor the feeding tolerance and prevent aspiration. The nurse should measure the gastric residual before each intermittent feeding or every 4 to 6 hr during continuous feeding¹².
Choice B reason: Flushing the client's tube with 30 mL of water every 4 hr is an appropriate action to maintain the tube patency, prevent clogging, and hydrate the client. The nurse should flush the tube before and after each medication administration, feeding, or gastric residual check¹³.
Choice C reason: Keeping the client's head elevated at 15° during feedings is not sufficient to prevent reflux and aspiration. The nurse should elevate the head of the bed at least 30° to 45° during feedings and for at least 30 min to 1 hr after feedings¹⁴.
Choice D reason: Obtaining the client's electrolyte levels every 4 hr is not necessary unless the client has signs of fluid or electrolyte imbalance, such as edema, dehydration, or abnormal vital signs. The nurse should monitor the client's weight, intake and output, and laboratory values as ordered by the provider¹⁵.
Correct Answer is C
Explanation
Choice A reason: Calcium is not a dietary supplement that can help with wound healing, although it is important for bone health and muscle contraction. Calcium deficiency can cause osteoporosis, muscle cramps, and abnormal heart rhythms, but it does not affect wound healing.
Choice B reason: Potassium is not a dietary supplement that can help with wound healing, although it is essential for nerve and muscle function and fluid balance. Potassium deficiency can cause weakness, fatigue, arrhythmias, and muscle cramps, but it does not affect wound healing.
Choice C reason: Vitamin C is a dietary supplement that can help with wound healing, as it is involved in collagen synthesis, tissue repair, and immune response. Vitamin C deficiency can cause scurvy, which is characterized by bleeding gums, poor wound healing, and anemia.
Choice D reason: Vitamin D is not a dietary supplement that can help with wound healing, although it is necessary for calcium absorption, bone health, and immune function. Vitamin D deficiency can cause rickets, osteomalacia, and increased risk of infections, but it does not affect wound healing.
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