The nurse is caring for a 2-year-old patient. Which observation requires immediate action by the nurse?
The identification band has fallen off the patient's leg.
The IV fluid is 48 hours old.
The crib rails are halfway up.
The bed linen is damp.
The Correct Answer is B
Choice A rationale:
The identification band falling off the patient's leg is a documentation concern and doesn't require immediate action unless the patient is at risk of wandering or abduction.
Choice B rationale:
IV fluids should be changed every 24 hours to prevent bacterial growth and infection. Using fluids that are 48 hours old increases the risk of introducing infection to the patient.
Choice C rationale:
The crib rails being halfway up is not an immediate concern unless the child is at risk of falling or climbing out of the crib.
Choice D rationale:
Damp bed linen can be addressed during the next bedding change. It may not require immediate action unless the patient's skin integrity is at risk.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Misdiagnosis is unlikely since the glucose levels are improving, indicating a valid diagnosis.
Choice B rationale:
Insulin-producing cells don't regenerate in substantial amounts to normalize glucose levels within a month. This process takes longer.
Choice C rationale:
This choice correctly identifies the situation as a temporary improvement due to the remaining insulin-producing cells functioning better temporarily.
Choice D rationale:
Complete recovery is not likely in such a short time frame.
Correct Answer is D
Explanation
The correct answer is choice d. Places the child in a prone position after feeding.
Choice A rationale:
Holding the child’s head in an upright position during feeding is appropriate as it helps prevent aspiration and ensures proper swallowing.
Choice B rationale:
Placing the tip of the syringe in the side of the child’s mouth is correct because it helps direct the formula to the back of the mouth, reducing the risk of choking.
Choice C rationale:
Burping the child frequently during the feeding is necessary to release any swallowed air, which can help prevent discomfort and spitting up.
Choice D rationale:
Placing the child in a prone position after feeding is incorrect and indicates a need for further instructions. After feeding, the child should be placed in an upright or slightly elevated position to prevent aspiration and reduce the risk of gastroesophageal reflux.
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