The practical nurse (PN) is caring for a 3-month-old male infant two days after a pylorotomy and notices that the infant is restless, grimacing, and drawing his knees to his chest. What action should the PN implement?

Obtain blood glucose level.

Burp the infant every two-hours.

Wrap him with a warm blanket.

Give prescribed analgesic.

Answer and Explanation

The Correct Answer is D

Choice A: Obtaining a blood glucose level is not the most relevant intervention for an infant displaying signs of discomfort or pain, such as restlessness, grimacing, and drawing knees to the chest.

Choice B: Burping the infant every two hours is a routine care measure for infants but may not address the specific signs of discomfort described in this scenario.

Choice C: Wrapping the infant with a warm blanket may provide comfort but does not directly address the underlying issue of restlessness and discomfort.

Choice D: Giving the prescribed analgesic is the most appropriate action for addressing the infant's signs of distress, such as restlessness, grimacing, and drawing knees to the chest. These signs suggest the possibility of pain, and administering the prescribed pain medication can help alleviate the discomfort.

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Correct Answer is B

Explanation

Choice A: This is important for the client's overall health but is not the most immediate priority in managing diabetes.

Choice B: The most important intervention for this client is to address lifestyle factors that contribute to diabetes and overall health. Weight loss and dietary changes are key components of managing type 2 diabetes. The client's weight is significantly above a healthy range, and losing 2 pounds (1 kg) per week is a reasonable and safe goal.

Choice C: Encouraging family members to be tested for diabetes is relevant but does not directly address the client's own management of the condition.

Choice D: Determining the client's feelings about the diagnosis is important for emotional support but does not directly address the client's physical health and diabetes management.

A. Double room with a 4-month-old who has RSV. B. Private room with negative air pressure. C. Private room furthest from the nurses station. D. Double room with a 6-month-old on droplet precautions.

Correct Answer is A

Explanation

A. Double room with a 4-month-old who has RSV: This is the best option. RSV is highly contagious but children with the same infection may be cohorted (roomed together) to minimize transmission to other clients and conserve private rooms for uninfected or immunocompromised children.
B. Private room with negative air pressure: Negative pressure rooms are reserved for airborne infections like tuberculosis, not RSV, which is spread through contact and droplets.
C. Private room furthest from the nurses station: While a private room is acceptable, location relative to the nurses station is not a priority. Cohorting with another RSV-positive child is equally effective.
D. Double room with a 6-month-old on droplet precautions: Unless the other child also has confirmed RSV, placing them together risks spreading the virus if their infections differ. Droplet precautions alone do not confirm the same diagnosis.

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The practical nurse (PN) is caring for a 3-month-old male infant two days after a pylorotomy and notices that the infant is restless, grimacing, and drawing his knees to his chest. What action should the PN implement?

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Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

The nurse-manager of a pediatric unit needs to assign a room for a 6-month-old diagnosed with respiratory syncytial virus (RSV). Which room assignment is best for the nurse-manager to make?

Correct Answer is A

Explanation

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