A nurse is caring for a client who has fluid volume deficit and is receiving a continuous IV infusion. Which of the following findings indicates the treatment has been effective?

Oliguria

Elastic skin turgor

Tachycardia

Dry mucous membranes

Answer and Explanation

The Correct Answer is B

A) Oliguria, or decreased urine output, is a sign of fluid volume deficit rather than an indication that the treatment has been effective. In a client with fluid volume deficit, the kidneys conserve water to maintain fluid balance, leading to decreased urine output.

B) Elastic skin turgor is a reliable indicator of hydration status. When a client's fluid volume deficit is improving, their skin turgor returns to normal. Elastic skin turgor means that the skin quickly returns to its normal position after being pinched and released, indicating adequate hydration.

C) Tachycardia, or an increased heart rate, is a compensatory mechanism that the body uses to maintain cardiac output in response to fluid volume deficit. While tachycardia may initially be present in a client with fluid volume deficit, it is not an indication that treatment has been effective.

D) Dry mucous membranes are a manifestation of dehydration and fluid volume deficit. Moist mucous membranes indicate hydration status, and their dryness suggests dehydration. Dry mucous membranes are not indicative of effective treatment for fluid volume deficit.

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Correct Answer is A

Explanation

A) If the infant turns away after taking most of the feeding, it's a sign that they are full. Continuing to feed them after they ’ave indicated fullness can lead to overfeeding and discomfort. Therefore, it's important for the parents to recognize cues of satiety and sto’ the feeding accordingly.

B) Formula should not be changed to whole milk until the infant is at least 12 months old. Whole milk is not recommended as a replacement for formula before this age because it does not provide the appropriate balance of nutrients required for infant growth and development.

C) Formula that remains in the bottle should not be saved for another feeding because bacteria from the infant's mouth can contaminate the formula, increasing the risk of infe’tion. Any unused formula should be discarded after the feeding session.

D) Diluting formula to slow down weight gain is not recommended and can lead to inadequate nutrition for the infant. Infants should receive the appropriate concentration of formula to meet their nutritional needs for growth and development. If concerns arise about weight gain, parents should consult with their healthcare provider for appropriate guidance and recommendations.

A. Initiate early feeding. B. Suction excess mucus with a bulb syringe. C. Prepare for an exchange blood transfusion. D. Begin phototherapy.

Correct Answer is A

Explanation

A) Initiate early feeding:

Early and frequent breastfeeding or formula feeding helps stimulate bowel movements, which aid in the elimination of bilirubin from the body. Breast milk also contains substances that promote bilirubin excretion, making early feeding an effective preventive measure against neonatal jaundice.

B) Suction excess mucus with a bulb syringe:

While clearing excess mucus can facilitate breathing and feeding, it does not directly prevent jaundice.

C) Prepare for an exchange blood transfusion:

Exchange transfusion is a treatment option for severe jaundice that has not responded to other measures. It is not a preventive measure.

D) Begin phototherapy:

Phototherapy is a treatment for jaundice after it has occurred, not a preventive measure. It involves exposing the newborn's skin to specific wavelengths of light to break down excess bilirubin.

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A nurse is caring for a client who has fluid volume deficit and is receiving a continuous IV infusion. Which of the following findings indicates the treatment has been effective?

Nursing Test Bank

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