A nurse is assessing an infant who has water intoxication. Which of the following findings should the nurse expect?

Generalized edema

Elevated urine specific gravity

Thready pulse

Increased hematocrit

Answer and Explanation

The Correct Answer is C

A. Water intoxication can lead to dilutional hyponatremia, which may result in fluid shifting into cells, causing cellular swelling and potentially cerebral edema, but generalized edema is not typically associated with water intoxication.

B. Water intoxication leads to dilution of electrolytes, including sodium, which results in decreased urine specific gravity rather than elevated.

C. Thready pulse is a common finding in water intoxication due to electrolyte imbalances and hemodilution.

D. Increased hematocrit is not typically associated with water intoxication; rather, it may indicate dehydration or hemoconcentration.

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Correct Answer is C

Explanation

A. Encourage the client to ambulate in the hallway 1 hr before bedtime - While light exercise during the day can promote better sleep, exercising close to bedtime can actually disrupt sleep.

B. Tell the client to avoid drinking fluids 1 hr before bedtime - While limiting fluids close to bedtime can reduce nighttime awakenings to urinate, it may not directly address difficulty falling asleep.

C. Schedule routine care tasks during hours when the client is awake - This action ensures that the client can maximize restful sleep during the night by minimizing disruptions from care

activities.

D. Advise the client to leave the television in the room on when trying to fall asleep - Screen

time before bed can interfere with falling asleep due to the stimulating effect of light and content.

A. Hydrogen peroxide B. Isopropyl alcohol C. Chlorine bleach D. Chlorhexidine

Correct Answer is C

Explanation

A. Hydrogen peroxide is not recommended for cleaning surfaces contaminated with blood as it is not as effective as other agents and may not adequately disinfect surfaces.

B. Isopropyl alcohol can be effective for disinfecting surfaces contaminated with blood, but it is less effective against certain bloodborne pathogens like hepatitis B virus compared to chlorine bleach.

C. Chlorine bleach is an effective agent for cleaning surfaces contaminated with blood and is recommended by CDC guidelines for disinfecting against bloodborne pathogens.

D. Chlorhexidine is primarily used as a skin antiseptic and is not typically used for cleaning surfaces contaminated with blood.

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A nurse is assessing an infant who has water intoxication. Which of the following findings should the nurse expect?

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