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Patient Data

History and Physical Nurses' Notes Laboratory Results Flow Sheet

Exhibits here

Review H and P, nurse's note, laboratory result, and flow sheet.

What information should the nurse collect as part of the focused assessment for dehydration in this child? Select all that apply.

Level of consciousness

Capillary refill

Temperature

Blood pressure

Pupil size and reactiveness

Skin turgor

Heart rate

Answer and Explanation

Correct Answer : B,C,D,G,H

Capillary refill: This is a quick and simple way to assess the adequacy of peripheral perfusion and can help identify signs of dehydration.
Skin turgor: Assessing the skin turgor, or the elasticity of the skin, is another useful indicator of dehydration.
Heart rate: Tachycardia can be a sign of dehydration, so monitoring the heart rate is an important component of the assessment.
Blood pressure: Blood pressure can be affected by dehydration, so monitoring it is important in determining the severity of dehydration and in guiding appropriate interventions.
Temperature: Fever is a potential cause of dehydration, so monitoring the temperature is an important part of the assessment.
Skin color of hands and feet: Checking the color of the skin on the hands and feet can help identify signs of poor perfusion and dehydration.

Assessing the level of consciousness, pupil size and reactiveness, and respiratory rate are important aspects of the neurological and respiratory assessments but are not specific to the assessment of dehydration.

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Correct Answer is A

Explanation

Septic shock is a life-threatening condition characterized by a severe infection that leads to systemic inflammation, organ dysfunction, and low blood pressure. Maintaining strict intake and output monitoring is essential to assess the client's fluid balance and response to interventions. It allows the nurse to closely monitor the client's urine output, which is a crucial indicator of renal perfusion and overall organ function.

Monitoring urine output helps the nurse assess the adequacy of tissue perfusion and the client's response to fluid resuscitation. A decrease in urine output can be an early sign of worsening organ dysfunction and a need for further interventions.

While assessing the warmth of extremities is important for evaluating peripheral perfusion, maintaining strict intake and output monitoring takes priority as it provides more comprehensive information about the client's overall fluid status.

Raising the head of the bed 45 degrees (semi-Fowler's position) can help optimize respiratory function and reduce the risk of aspiration, but it is not the most important intervention in this case.

Monitoring blood glucose levels is important, as hyperglycemia can be associated with sepsis. However, in the context of septic shock, maintaining strict intake and output monitoring takes precedence as it directly assesses the client's fluid balance and response to interventions.

It's crucial to note that the management of septic shock requires a multidisciplinary approach, and other interventions, such as administering appropriate antibiotics, initiating fluid resuscitation, and addressing the underlying source of infection, should also be implemented in a timely manner.

A. Encourage the use of ice on the areola. B. Teach about the use of a breast pump. C. Offer supplemental formula feedings. D. Recommend using a breast shield. E. None F. None

Correct Answer is D

Explanation

Choice A rationale: Applying ice can cause vasoconstriction and potentially inhibit the let-down reflex. While it might temporarily firm the tissue, it does not effectively address the anatomical challenge of inverted nipples.

Choice B rationale: While a pump can help draw out a nipple or maintain supply, the immediate concern is the baby's inability to latch at the breast for a successful feeding session.

Choice C rationale: Offering formula as a first-line intervention can undermine the mother's breastfeeding goals and interfere with the establishment of her milk supply and the infant's natural sucking reflex.

Choice D rationale: A breast shield is a silicone device that fits over the nipple and areola, providing a firm, protruded surface for the infant to latch onto when nipples are flat.

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Patient Data History and Physical Nurses' Notes Laboratory Results Flow Sheet Exhibits here Review H and P, nurse's note, laboratory result, and flow sheet. What information should the nurse collect as part of the focused assessment for dehydration in this child? Select all that apply.

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Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

A client who is one day postpartum tells the nurse that her baby cannot latch onto the breast. The nurse determines that the client's nipples are inverted. Which action should the nurse implement?

Correct Answer is D

Explanation

The nurse is preparing to administer 1.6 mL of medication intramuscularly to a 4-month-old infant. Which action should the nurse include?

Review H and P and nurse's notes. What are the first four actions that the nurse should take?

The practical nurse (PN) reports that a client who has a fingerstick glucose of 35 mg/dL (1.94 mmol/L) is alert and diaphoretic. Which action should the charge nurse take? Reference Ranges Glucose [Reference Range: 0 to 50 years: 74 to 106 mg/dL (4.1 to 5.9 mmol/L)]

When the nurse enters the room of a male client who was admitted for a fractured femur, his cardiac monitor displays a normal sinus rhythm (NSR), but he has no spontaneous respirations and his carotid pulse is not palpable. Which intervention should the nurse implement?

A client is being discharged home after being treated for heart failure (HF). Which instruction should the nurse include in this client's discharge teaching plan?

A client with a history of chronic obstructive pulmonary disease (COPD) is admitted with pneumonia. Vital signs include: heart rate 122 beats/minute, respiratory rate 28 breaths/minute, and blood pressure 170/90 mmHg. Which assessment finding warrants the most immediate intervention by the nurse?

The nurse is caring for a client who reports running out of aspirin 1 week ago and taking ibuprofen as a replacement. Which information should the nurse obtain from the client first?

Patient Data

History and Physical Nurses' Notes Laboratory Results Flow Sheet

Exhibits here

Review H and P, nurse's note, laboratory result, and flow sheet.

What information should the nurse collect as part of the focused assessment for dehydration in this child? Select all that apply.