A nurse is caring for an 8-month-old infant who has received a bolus of IV fluid for hypovolemic shock. Which of the following findings indicates the treatment was effective?
Temperature 38.6° C (101.5° F)
Sunken anterior fontanel
Tachycardia
Capillary refill is 2 seconds
The Correct Answer is D
A. "Temperature 38.6° C (101.5° F)." A fever is not an indicator of improved hydration or effective fluid resuscitation. It may be related to an underlying infection, which could contribute to hypovolemia.
B. "Sunken anterior fontanel." A sunken fontanel is a sign of dehydration, indicating that the fluid replacement was not fully effective. If the treatment were successful, the fontanel should be normal (flat and soft).
C. "Tachycardia." Tachycardia is a sign of ongoing hypovolemia or distress. If fluid resuscitation was effective, the heart rate should return to normal for the infant's age.
D. "Capillary refill is 2 seconds." A capillary refill time of 2 seconds or less indicates adequate peripheral perfusion and improved circulation, showing that the fluid bolus was effective in restoring blood volume and perfusion.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A,B,C"},"C":{"answers":"B,C"},"D":{"answers":"B"}}
Explanation
Bacterial Meningitis (Most Likely Diagnosis). Headache, nausea, irritability, lethargy, nuchal rigidity → Signs of meningeal irritation Petechiae → Possible meningococcal sepsis. Fever, chills, elevated WBC count (14,000/mm³) → Indicates an infection. Irregular respirations, agitation, capillary refill 4 seconds → Signs of worsening perfusion, possible sepsis
Hodgkin Lymphoma (Possible but Less Likely). Enlarged lymph nodes → Common in lymphoma but does not explain acute symptoms like fever, petechiae, or neurologic signs.
Acute Lymphoblastic Leukemia (ALL) (Possible but Less Likely). Petechiae → Possible due to thrombocytopenia, but child’s platelet count (350,000) is normal.. Enlarged lymph nodes → Can occur in leukemia but is not the primary concern given the acute symptoms.
Correct Answer is A
Explanation
A. "Wear a face mask when working within 3 feet of a child who is infected." Influenza spreads through droplets, so wearing a face mask within 3 feet of an infected child helps prevent transmission.
B. "Administer antibacterial medication within 24 hr of the onset of symptoms." Influenza is caused by a virus, not bacteria, so antibacterial medications (antibiotics) are not effective. Antiviral medications (e.g., oseltamivir) may be given within 48 hours of symptom onset.
C. "Children should be considered infectious for 14 days after the onset of symptoms." . Children with influenza are most contagious 1 day before symptoms appear and up to 5 to 7 days after onset.
D. "Administer the influenza vaccine every 6 months." The influenza vaccine is given annually (once per year), not every 6 months.
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