During a daily assessment in the nursery, the practical nurse (PN) notices three large bluishblack areas on the back and buttocks of an African-American infant. Which action should the PN take?

A Write an incident report about the bruises on the infant.

B Review the labor and delivery record for birth trauma.

C Record the size and location of the areas in the infant's chart.

D Notify the pediatrician of a possible bleeding problem with the infant.

Answer and Explanation

The Correct Answer is C

A.   Write an incident report about the bruises on the infant. - These areas might not be bruises; hence, writing an incident report without accurate information could be premature.
B.   Review the labor and delivery record for birth trauma. - While important, it might not directly relate to the observed bluish-black areas.
C.   Record the size and location of the areas in the infant's chart. - Documenting the observations is essential for tracking changes and informing other healthcare providers.
D.   Notify the pediatrician of a possible bleeding problem with the infant. - Without further assessment, assuming a bleeding problem might be premature and unnecessarily alarming.

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Correct Answer is C

Explanation

A. Encouraging the client to use the spirometer before analgesia can increase discomfort and reduce effort, leading to ineffective deep breathing. Pain control should be optimized first to promote participation and proper technique.

B. Delaying instruction for several hours postpones an important postoperative intervention that helps prevent complications such as atelectasis. Early and consistent use of the spirometer is essential for optimal recovery.

C. Administering a PRN analgesic first improves comfort, allowing the client to take deeper breaths and use the spirometer effectively. This approach supports both pain management and respiratory function, making it the best choice.

D. Reassuring the client that the spirometer is not painful dismisses the client’s concern and does not address the need for pain control. Postoperative clients often experience pain with deep breathing, so appropriate analgesia is necessary.

A. "May I sit with you for a while?" B. "Why do you want to stay in your room today?" C. "Come into the recreation area. We have your favorite card game and I will play it with you." D. "I know you are sad about not seeing your family as often, but they are visiting as much as they can."

Correct Answer is A

Explanation

A. "May I sit with you for a while?" - This response offers companionship and emotional support without pushing the resident to engage in an activity or prying into his feelings. It respects his desire for solitude while providing the option for company if he wishes.
B. "Why do you want to stay in your room today?" - This might be perceived as intrusive and pushy, potentially making the resident more withdrawn.
C. "Come into the recreation area. We have your favorite card game and I will play it with you." - While well-intentioned, this suggestion may not align with the resident's current emotional state or desire for solitude.
D. "I know you are sad about not seeing your family as often, but they are visiting as much as they can." - This response acknowledges the resident's feelings but may not address his immediate need for companionship or support.

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During a daily assessment in the nursery, the practical nurse (PN) notices three large bluishblack areas on the back and buttocks of an African-American infant. Which action should the PN take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The practical nurse (PN) is explaining the use of an incentive spirometer to a postoperative client. The client asks the PN to administer an analgesic before using the spirometer. How should the PN respond?

Correct Answer is C

Explanation

A chronically depressed older male resident of a long-term care facility has become more reclusive and today refuses to leave his room. His family has away and are unable to visit as much as in the past. Which comment by the practical nurse (PN) is likely to be most helpful to this client?

Correct Answer is A

Explanation

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