A nurse is caring for a 6-month-old infant who has a prescription for clear liquids by mouth after a repair of an intussusception. Which of the following fluids should the nurse select for the infant?
Half-strength orange juice
Half-strength infant formula
Full-strength apple juice
Full-strength chicken broth
The Correct Answer is B
Choice A reason: Half-strength orange juice is not a good choice for the infant, as it is acidic and may irritate the gastrointestinal tract. It also does not provide adequate calories or nutrition for the infant.
Choice B reason: Half-strength infant formula is a suitable choice for the infant, as it is bland and easy to digest. It also provides some calories and nutrition for the infant, who may have lost fluids and electrolytes due to the intussusception.
Choice C reason: Full-strength apple juice is not a good choice for the infant, as it is high in sugar and may cause diarrhea. It also does not provide adequate calories or nutrition for the infant.
Choice D reason: Full-strength chicken broth is not a good choice for the infant, as it is high in sodium and may cause dehydration. It also does not provide adequate calories or nutrition for the infant..
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: A child with Hirschsprung disease may require a temporary or permanent ostomy, depending on the extent of the bowel affected. The parent should be prepared for either outcome and not assume that the ostomy is only temporary.
Choice B reason: A child with Hirschsprung disease will not have normal bowel movements immediately after the surgery, as the bowel needs time to heal and adapt. The parent should be aware of the possible complications and follow-up care that the child will need.
Choice C reason: A child with Hirschsprung disease may need a feeding tube after the surgery to provide adequate nutrition and hydration while the bowel recovers. The parent should express interest in learning how to use and care for the feeding tube, as this indicates an understanding of the teaching.
Choice D reason: A child with Hirschsprung disease will not need a urinary catheter after the surgery, unless there is a specific indication for it. The parent should not confuse the feeding tube with the urinary catheter, as this indicates a lack of understanding of the teaching.
Correct Answer is C
Explanation
Choice A reason: 60 beats per minute is too low for an infant's apical heart rate. The normal range for a 6-month-old infant is 100 to 160 beats per minute. A low heart rate can indicate digoxin toxicity, which can cause serious complications such as bradycardia, arrhythmias, and cardiac arrest.
Choice B reason: 80 beats per minute is also too low for an infant's apical heart rate. The normal range for a 6-month-old infant is 100 to 160 beats per minute. A low heart rate can indicate digoxin toxicity, which can cause serious complications such as bradycardia, arrhythmias, and cardiac arrest.
Choice C reason: 100 beats per minute is the lower limit of the normal range for a 6-month-old infant's apical heart rate. The nurse should withhold the dose of digoxin if the infant's apical heart rate is less than 100 beats per minute, as this can indicate digoxin toxicity, which can cause serious complications such as bradycardia, arrhythmias, and cardiac arrest.
Choice D reason: 120 beats per minute is within the normal range for a 6-month-old infant's apical heart rate. The nurse does not need to withhold the dose of digoxin if the infant's apical heart rate is 120 beats per minute, as this does not indicate digoxin toxicity. However, the nurse should still monitor the infant's heart rate, blood pressure, and digoxin level closely, as digoxin has a narrow therapeutic window and can cause adverse effects even at therapeutic doses.
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