NCLEX Quiz: Basic Care and Comfort June 3, 2015 By Rana Waqar Leave a Comment 1. The nurse is assessing an irritable 6-month old infant during a well-baby checkup. The infant’s weight is 19 lb., 6.4 oz. (8.8 kg). The infant does not have an elevated temperature, the heart rate is 102, and the respiratory rate is 32. The mother states that the infant wakes every hour or two throughout the night. The infant wants a bottle, and falls asleep while eating, but doesn’t stay asleep. Which of the following instructions should the nurse give the parents?* 1. Instruct the parents to offer acetaminophen 325 mg orally for comfort, and diphenhydramine 25 mg orally for sleep. 2. Instruct the parents to offer high-calorie solid foods during daytime hours so the infant does not wake up hungry during the night. 3. Instruct the parents to offer the last feeding as late as possible, and put the infant to bed awake without a bottle. 4. Suggest using pacifiers, taking the infant to the parent’s bed, or rocking the infant to sleep. 2. The nurse caring for a child burned over 20% of her body assists the physician in performing dressing changes on day 5 after the initial injury. The child appears disoriented, has a fever of 101º F (38.3º C), and is crying in pain. Which of the following nursing interventions would be the MOST appropriate in caring for this client?* 1. Gather equipment for the dressing change and explain the procedure to the child. 2. Do a complete physical assessment and notify the physician of the findings. 3. Administer appropriate analgesics and gather equipment for the dressing change. 4. Offer the child an enticing distraction from pain, such as a video, music, or toy. 3. The nurse is taking care of a young child a few hours after a tonsillectomy. Which of the following nursing interventions would be appropriate to promote adequate nutrition and oral hydration for this child?* 1. Offer the child warm soup, watch for signs of bleeding, and suction vigorously to remove old blood. 2. Offer ice chips after the child awakens; advance to cool, clear liquids; and suction gently to remove oral secretions without causing the child to cough or gag. 3. Maintain the intravenous fluids appropriate for the child’s weight for the next 24 hours and keep the child NPO. 4. Offer soft, warm foods so the child will not be hungry; orange juice to provide vitamin C; and milk shakes for calories. 4. The nurse is caring for a child who had an adenoidectomy and tonsillectomy 10 hours ago. The parents are in the room and preparing the child for bedtime. Which of the following nursing interventions would be helpful to promote rest and sleep for this client?* 1. Provide a cool water rinse, adjust the head of the bed to a 30–45-degree angle, and offer an ice collar for comfort. 2. Encourage the parents to leave so the child can sleep. 3. Suction vigorously before the child falls asleep to ensure the child has a patent air way. 4. Provide a water rinse, offer an ice collar for discomfort, and assist the child in finding a position of comfort while promoting a patent airway for sleep. 5. The nurse has been assigned to an adult male client who is less than 24 hours post-op. In report, the nurse learns that he rings his call light frequently, is anxious, and has had pain medication as ordered. Which of the following nondrug nursing interventions should the nurse include when caring for this client?* 1. Assure the client his anxiety is understandable, because the pain medication needs time to take effect. 2. Assess other clients first, giving this client time to relax before evaluating his level of pain. 3. Call the client’s physician to increase the amount or frequency of pain medications ordered. 4. Provide a quiet environment, offer repositioning, straighten the bed linens, offer fluids, and assess his pain level. Δ
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