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 infant formula

Sterile water

Oral electrolyte solution

Half-strength orange juice

Answer and Explanation

The Correct Answer is C

A. Half-strength infant formula: Infant formula, even if diluted, may not be appropriate immediately after a repair of intussusception. It may be too heavy for the infant's digestive system, potentially leading to complications. Clear fluids are usually preferred initially.

B. Sterile water: Sterile water is not typically recommended for oral intake in infants after a repair of intussusception. It lacks essential electrolytes needed to maintain proper hydration and electrolyte balance.

C. Oral electrolyte solution: Oral electrolyte solutions, such as Pedialyte, are often recommended for infants after a repair of intussusception. These solutions contain balanced electrolytes and fluids, which help prevent dehydration and restore electrolyte balance.

D. Half-strength orange juice: Orange juice, even if diluted, is not typically recommended immediately after a repair of intussusception. It may be too acidic and may cause gastrointestinal discomfort or irritation in the infant. Clear fluids are preferred initially to allow the gastrointestinal tract to rest and recover.

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Correct Answer is B

Explanation

A. Barking cough: A barking cough is a characteristic symptom of acute laryngotracheobronchitis (croup), indicating inflammation of the upper airway. While it may improve with treatment, it is not necessarily an indication that the treatment has been effective on its own.

B. Decreased stridor: Stridor is a high-pitched, wheezing sound heard during inspiration and indicates upper airway obstruction. In acute laryngotracheobronchitis, stridor is a prominent symptom. Decreased stridor suggests that the airway obstruction is resolving, which indicates that the treatment has been effective.

C. Decreased temperature: While fever may be present in some cases of acute laryngotracheobronchitis, it is not a defining characteristic. A decreased temperature alone does not necessarily indicate that the treatment has been effective in managing the condition.

D. Improved hydration: Hydration is important in managing any illness, including acute laryngotracheobronchitis, but improved hydration alone does not indicate that the treatment has been effective in resolving the condition. It may be an important aspect of supportive care but does not directly reflect the resolution of airway obstruction.

A. A client requests extra blankets when the thermostat in the room indicates 25.6° C (78° F). B. A client wants to know the current time while there is a clock on the wall. C. A client refuses to get out of bed and has no motivation to attend to daily hygiene. D. A client attempts to climb out of bed and repeatedly states she must get home.

Correct Answer is D

Explanation

A. A client requests extra blankets when the thermostat in the room indicates 25.6° C (78° F): This behavior does not necessarily indicate delirium. It could be a response to feeling cold or a preference for additional warmth. While it may warrant further assessment, it is not a classic manifestation of delirium.

B. A client wants to know the current time while there is a clock on the wall: Asking about the time does not specifically indicate delirium. The client may simply want confirmation or may not have noticed the clock on the wall. This behavior is more likely related to memory or orientation than delirium.

C. A client refuses to get out of bed and has no motivation to attend to daily hygiene: This behavior may be concerning and could indicate depression or another mental health issue, but it is not a classic manifestation of delirium. Delirium typically involves acute changes in mental status, including confusion, disorientation, and fluctuating levels of consciousness.

D. A client attempts to climb out of bed and repeatedly states she must get home: This behavior is indicative of delirium. Attempting to leave the bed or facility and expressing a strong desire to go home, especially when it is not feasible or safe to do so, is a classic manifestation of delirium. Delirium often involves confusion, agitation, and impaired judgment, leading the individual to act in ways that are out of character or irrational.

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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?

Nursing Test Bank

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