A nurse is assisting with the admission of an infant who has experienced vomiting and loose, watery stools for the past 3 days. Which of the following findings indicates that the child is experiencing moderate dehydration?

Anuria

A 7% weight loss from baseline

Нуреrpnea

Lethargy

Answer and Explanation

The Correct Answer is B

A. Anuria: Anuria, or the absence of urine output, indicates severe dehydration or acute renal failure rather than moderate dehydration. Moderate dehydration usually presents with decreased but not absent urine output, as the body still tries to conserve fluids.

B. A 7% weight loss from baseline: A weight loss of 6% to 9% of body weight is consistent with moderate dehydration in infants and children. This measurable sign is a critical and objective indicator used to assess the severity of dehydration, particularly following prolonged vomiting or diarrhea.

C. Hyperpnea: Hyperpnea, or abnormally deep and rapid breathing, can be seen in cases of severe dehydration or metabolic acidosis. It is not a classic finding of moderate dehydration, where respiratory patterns are usually normal or only mildly affected.

D. Lethargy: Lethargy typically suggests severe dehydration rather than moderate. In moderate dehydration, the infant may be irritable or thirsty but usually maintains normal mental status without profound decreases in responsiveness or alertness.

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Correct Answer is B

Explanation

A. Acute hemolytic: An acute hemolytic reaction typically presents with symptoms like fever, chills, back pain, hypotension, and hematuria. It is caused by the recipient’s immune system attacking incompatible donor red blood cells, not primarily by urticaria and wheezing.

B. Anaphylactic: An anaphylactic reaction is a severe allergic response to blood transfusion and is characterized by symptoms such as urticaria (hives), wheezing, hypotension, and respiratory distress. It requires immediate intervention, including stopping the transfusion and administering emergency medications.

C. Febrile: A febrile reaction is usually marked by fever, chills, and headache during or shortly after a transfusion. It does not typically involve wheezing or significant allergic skin reactions like urticaria.

D. Circulatory overload: Circulatory overload occurs when too much fluid is administered too quickly, leading to symptoms like dyspnea, cough, and pulmonary edema. While it involves respiratory symptoms, it is not associated with urticaria or allergic reactions.

A. Assist with administration of AB positive blood products if needed. B. Prepare client for insertion of 18-gauge peripheral IV prior to surgery. C. Administer Rh, D immune globin prior to surgery. D. Obtain a complete blood count. E. Explain the surgical procedure to the client. F. Remind client to be NPO prior to surgery. G. Verify consent form is signed by the client.

Correct Answer is ["B","C","D","F","G"]

Explanation

Prepare client for insertion of 18-gauge peripheral IV prior to surgery: A large-bore IV catheter, such as an 18-gauge, is necessary before surgery to ensure rapid administration of fluids, medications, or blood products if needed during the procedure. It is a measure to support hemodynamic stability during anesthesia and surgery.
Administer Rh, D immune globin prior to surgery: The client's blood type is B negative. Because an ectopic pregnancy involves fetal tissue, and there's a potential for fetal-maternal blood mixing during the surgery, administering Rh(D) immune globulin (RhoGAM) is crucial to prevent Rh sensitization in Rh-negative women who may be carrying an Rh-positive fetus. This is typically given within 72 hours of a potential sensitizing event.
Obtain a complete blood count: A CBC is critical to assess hemoglobin, hematocrit, and platelet levels before surgery. This helps the healthcare team anticipate the risk of bleeding and determine if transfusions might be necessary during or after the laparoscopic procedure.
Explain the surgical procedure to the client: Explaining the surgical procedure is the provider's responsibility, not the nurse's role. The nurse can reinforce teaching and answer basic questions but should not be the primary person explaining the procedure or obtaining informed consent.
Remind client to be NPO prior to surgery: Maintaining NPO status is essential to reduce the risk of aspiration during anesthesia. The client should avoid eating or drinking for a specified time before surgery, following the facility's preoperative protocol.
Verify consent form is signed by the client: Verifying that the informed consent form is properly signed is a crucial nursing responsibility before surgery. It ensures legal compliance and confirms that the client has been informed about the procedure, risks, and alternatives.

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A nurse is assisting with the admission of an infant who has experienced vomiting and loose, watery stools for the past 3 days. Which of the following findings indicates that the child is experiencing moderate dehydration?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is monitoring a client who is receiving a blood transfusion. The nurse identifies that the client has urticaria and is wheezing. Which of the following types of transfusion reactions should the nurse suspect?

Correct Answer is B

Explanation

The nurse has reviewed the Nurses' Notes and Provider Prescriptions at 1100 and Diagnostic Results on Day 3. The nurse is preparing the client for surgery. Which of the following actions should the nurse take. Select all that apply.

Correct Answer is ["B","C","D","F","G"]

Explanation

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