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. Complete blood count: Primarily measures the number of blood cells and their types. It does not directly assess the effectiveness of warfarin.
B. Creatinine clearance: Evaluates kidney function and doesn't directly reflect the efficacy of warfarin.
C. Prothrombin time (PT): Measures the time taken for blood to clot, an essential indicator for monitoring anticoagulation therapy like warfarin.
D. Serum troponin levels: Assesses cardiac damage and is not indicative of warfarin's effectiveness in managing atrial fibrillation.

A. Insert lubricated tip of tubing 3 to 4 inches into the rectum. B. Position client in left lateral recumbent position to expose buttocks. C. Chill the enema solution to help reduce the client's fever. D. Encourage client to retain solution for at least 5 minutes. E. Clamping the enema administration tubing

Correct Answer is ["A","B","D","E"]

Explanation

A. Inserting the lubricated tip of the tubing 3 to 4 inches into the rectum allows for the proper administration of the enema.
B. Positioning the client in the left lateral recumbent position helps expose the rectum for the enema administration.
C. Chilling the enema solution isn't recommended as it might cause discomfort or shock to the client.
D. Encouraging the client to retain the solution for at least 5 minutes helps ensure effectiveness.

E. Clamping the enema administration tubing after filling the enema bag helps control the flow during the procedure.

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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

A client who was recently diagnosed with atrial fibrillation is receiving warfarin. To see the drug's effectiveness, which laboratory finding should the practical (PN) review?

Correct Answer is C

Explanation

The practical nurse (PN) is administering a saline enema to a client who was admitted because of a fever of unknown origin and is now constipated. Which techniques should the PN use? (Select all that apply.)

Correct Answer is ["A","B","D","E"]

Explanation

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