The parent of a 7-month-old brings the infant to the clinic because the skin in the diaper area is excoriated and red, but there are no blisters or bleeding. The parent reports no evidence of watery stools. Which nursing intervention should the nurse implement?

Ask the parent to decrease the infant's intake of fruits for 24 hours.

Instruct the parent to change the child's diaper more often.

Encourage the parent to apply lotion with each diaper change.

Tell the parent to cleanse with soap and water at each diaper change.

Answer and Explanation

The Correct Answer is B

Rationale

A. Fruits can sometimes increase stool acidity or frequency in infants, potentially aggravating diaper rash. However, unless there is a clear association between fruit intake and exacerbation of symptoms, restricting fruits for 24 hours may not directly address the current rash. It's more important to focus on topical care and diaper hygiene.

B. Changing diapers frequently helps keep the skin dry and reduces exposure to irritants like urine and stool. This intervention is crucial as prolonged exposure to moisture can contribute to diaper rash development and exacerbation.

C. Applying a barrier cream or diaper rash ointment can protect the skin from moisture and irritants, providing a protective layer that promotes healing. This intervention helps soothe the skin and prevent further irritation.

D. Using soap and water at every diaper change can be harsh on the delicate skin of infants, especially if the soap is not pH-balanced or contains fragrances. Plain water or a gentle, pH-balanced cleanser is preferable to avoid further irritation.

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Correct Answer is ["A","B","C"]

Explanation

Rationale

A. This involves visually inspecting the chest to ensure both sides rise and fall equally during ventilation. Symmetrical chest movement suggests that both lungs are being adequately ventilated.

B. Auscultation involves listening with a stethoscope over the chest to confirm the presence of breath sounds in both lung fields. Bilateral breath sounds indicate that the ETT is correctly positioned in the trachea, allowing air to reach both lungs.

C. A chest x-ray provides a definitive confirmation of the ETT placement in relation to the trachea and lungs. It allows visualization of the tube's position relative to anatomical landmarks, such as the carina, which helps ensure proper placement.

This involves checking the markings on the ETT tube to ensure it is inserted to the correct depth. Typically, the ETT should be positioned with its tip approximately 2 to 4 cm above the carina, which corresponds to the 22-26 cm mark at the teeth line in adults. However, it does not confirm correct placement.

E. Capillary refill is a measure of peripheral perfusion and is unrelated to ETT placement. It assesses circulatory status by pressing on a nail bed and observing the time it takes for color to return. It does not provide information about ETT placement.

A. Reposition the stethoscope over the brachial artery. B. Note the presence of an auscultatory gap. C. Continue with the blood pressure assessment. D. Reinflate the cuff to a higher number.

Correct Answer is B

Explanation

Rationale

A. Repositioning the stethoscope or reinflating the cuff may be necessary if the sounds are unclear or if there is difficulty in hearing the Korotkoff sounds, but these actions come after noting any auscultatory gap.

B. It's characterized by a period of silence between the appearance and disappearance of sounds. Noting its presence is important for accurately recording the blood pressure readings, as failure to recognize an auscultatory gap could lead to underestimating the systolic pressure.

C. After repositioning the stethoscope or noting the presence of an auscultatory gap, the nurse should proceed with the blood pressure assessment.

D. If the cuff was not inflated adequately during the initial inflation, the nurse may not have occluded the artery completely, leading to inaccurate readings. However, in this scenario where Korotkoff sounds

are heard, it indicates that the cuff pressure was sufficient to occlude and then release the artery's blood flow.

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The parent of a 7-month-old brings the infant to the clinic because the skin in the diaper area is excoriated and red, but there are no blisters or bleeding. The parent reports no evidence of watery stools. Which nursing intervention should the nurse implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A young adult is brought to the emergency department after taking a handful of drugs. The client is unresponsive, so an endotracheal tube (ETT) is inserted. How should the nurse determine if the ETT is correctly placed? Select all that apply.

Correct Answer is ["A","B","C"]

Explanation

After inflating a blood pressure cuff and releasing the valve, the nurse hears silence followed by a Korotkoff sound. Which action should the nurse take next?

Correct Answer is B

Explanation

A client is being treated for syndrome of inappropriate antidiuretic hormone (SIADH). On examination, the client has a weight gain of 4.4 lbs (2 kg) in 24 hours and an elevated blood pressure. Which intervention should the nurse implement first?

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A client receives a prescription for 1 L of lactated Ringer's IV to be infused over 12 hours. The IV administration set delivers 15 gtt/mL. How many gtt/min should the nurse regulate the infusion? (Enter numerical value only. If rounding is required, round to the nearest whole number.)

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