The parent of a 7-month-old infant visits the clinic due to the infant’s diaper area being red and raw, but without any blisters or bleeding.
The parent reports no signs of watery stools.
What nursing intervention should the nurse implement?

Advise the parent to reduce the infant’s fruit intake for 24 hours.

Recommend the parent to clean with soap and water at each diaper change.

Instruct the parent to change the child’s diaper more frequently.

Encourage the parent to apply lotion with each diaper change.

Answer and Explanation

The Correct Answer is C

Choice A rationale

Reducing the infant’s fruit intake for 24 hours is not the best approach in this situation. While certain fruits can cause diarrhea, the parent reports no signs of watery stools. Therefore, this intervention may not address the issue of the red and raw diaper area.

Choice B rationale

Cleaning with soap and water at each diaper change can actually worsen the condition. Soap can dry out the skin and disrupt the skin’s natural barrier, potentially leading to more irritation. It’s generally recommended to use water and a soft cloth, or a gentle non-soap cleanser, to clean the diaper area.

Choice C rationale

Changing the child’s diaper more frequently is the most appropriate intervention. A wet or dirty diaper can irritate the skin, leading to diaper rash. By changing the diaper more often, the skin is kept clean and dry, which can help the rash heal.

Choice D rationale

Applying lotion with each diaper change is not typically recommended for diaper rash. Some lotions can contain fragrances or other ingredients that can further irritate the rash. Instead, a barrier cream or ointment, such as one containing zinc oxide, is often recommended.

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Correct Answer is D

Explanation

Choice A rationale

Serum albumin levels can be relevant in assessing nutritional status and the body’s ability to heal wounds. However, they do not directly indicate the presence of infection or purulent drainage.

Choice B rationale

Hematocrit measures the percentage of red blood cells in the blood and is not directly related to the presence of purulent drainage at a burn wound site. Elevated hematocrit may indicate dehydration or hemoconcentration but does not specifically address the issue of wound infection.

Choice C rationale

Serum blood glucose (BG) level is not directly related to the presence of purulent drainage at a burn wound site. Elevated BG levels might be seen in clients with diabetes or as a stress response, but they are not the primary indicator of infection or wound complications.

Choice D rationale

Neutrophil count is a key laboratory value to note when a client with a full-thickness burn has purulent drainage at the wound. An elevated neutrophil count can indicate an infection, which could be the cause of the purulent drainage.

A. Transfer Patient D to an isolation room 24 hours prior to surgery. B. Increase Patient A’s oxygen to 4 L/minute via nasal cannula. C. Ensure that there are two units of packed cells available for Patient B. D. Request the dietitian to include a banana in Patient C’s breakfast tray.

Correct Answer is C

Explanation

Choice A rationale

There is no indication that Patient D, who is scheduled for an appendectomy and has a white blood cell (WBC) count of 14,000 mm² (14 x 10°/L), needs to be transferred to an isolation room 24 hours prior to surgery.

Choice B rationale

Patient A, diagnosed with emphysema and has an oxygen saturation of 94% on room air, does not necessarily need an increase in oxygen. An oxygen saturation of 94% is within normal limits.

Choice C rationale

Patient B, who is postoperative with a hemoglobin level of 8.2 mg/dL (82 g/L), may require a blood transfusion. A hemoglobin level of 8.2 mg/dL is low, and having packed cells available is a prudent measure.

Choice D rationale

Patient C, newly admitted with a potassium level of 3.8 mEq/L (3.8 mmol/L), has a normal potassium level. Including a banana in the breakfast tray is not a priority.

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The parent of a 7-month-old infant visits the clinic due to the infant’s diaper area being red and raw, but without any blisters or bleeding.The parent reports no signs of watery stools.What nursing intervention should the nurse implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

While caring for a client with a full thickness burn covering 40% of the body surface area (BSA), the nurse observes purulent drainage at the wound. Before reporting this finding to the healthcare provider, which of the client’s laboratory values should the nurse note?

Correct Answer is D

Explanation

Correct Answer is C

Explanation

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The parent of a 7-month-old infant visits the clinic due to the infant’s diaper area being red and raw, but without any blisters or bleeding.
The parent reports no signs of watery stools.
What nursing intervention should the nurse implement?