A nurse is caring for an infant who is admitted to the hospital for dehydrated and requires IV therapy. The nurse should monitor the infant's response to therapy by performing which of the following actions?
Measuring the infant's head circumference twice per day
Taking the infant's vital signs every 2 hr
Assessing the infant's Moro reflex
Weighing the infant at the same time every day
The Correct Answer is B
A. Head circumference measurement is important for monitoring growth and intracranial pressure, not acute hydration status.
B. Taking vital signs every 2 hours allows the nurse to closely monitor the infant’s cardiovascular status, perfusion, and response to IV fluid therapy, which are key indicators of hydration improvement.
C. The Moro reflex assesses neurologic function in infants and does not indicate fluid status.
D. Daily weights are useful for monitoring fluid balance over time but are less responsive than frequent vital signs for acute changes in hydration.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Bradycardia is not typically an early sign of circulatory overload; tachycardia is more common.
B. Flushing is nonspecific and not a reliable early indicator of fluid overload.
C. Vomiting may occur for various reasons postoperatively but is not an early sign of circulatory overload.
D. Dyspnea (shortness of breath) is an early and key sign of circulatory overload, reflecting pulmonary congestion.
Correct Answer is A
Explanation
A. Prednisone is a corticosteroid that can increase blood glucose levels, potentially counteracting the effects of metformin and requiring careful monitoring.
B. Acetaminophen does not significantly affect blood glucose levels and is generally safe for clients with diabetes.
C. Cephalexin, an antibiotic, does not typically alter blood glucose levels and is not contraindicated with metformin.
D. Lisinopril may slightly lower blood glucose in some cases but is generally safe for clients taking metformin and is not contraindicated.
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