The infant's anterior
The Correct Answer is {"dropdown-group-1":"A"}
A. Fontanel: The anterior fontanel is a soft spot on an infant’s skull where cranial bones have not yet fused. It becomes sunken with dehydration due to reduced intracranial and interstitial fluid and appears normal when the infant is adequately hydrated.
B. Thorax: The thorax does not show visible signs of sunken appearance with dehydration. Chest wall changes are unrelated to fluid status in infants.
C. Pupil: Pupils respond to light and neurological function, not hydration status. They do not become sunken during dehydration.
D. Nares: The nares (nostrils) may flare in respiratory distress but are not affected by hydration status and do not provide an indicator of fluid balance.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. At the measurement line: While graduated cylinders have marked measurement lines, the correct technique requires reading the meniscus rather than aligning the eye with a line on the cylinder. Measurement lines alone do not ensure accuracy.
B. At the base of the meniscus: Liquid in a cylinder forms a concave curve, and the correct volume is read at the lowest point of this meniscus at eye level. This method ensures precise measurement and prevents dosing errors.
C. At the bevel: The bevel refers to the slanted edge of a syringe needle, not a graduated cylinder. Reading at the bevel is irrelevant and would produce inaccurate volume readings.
D. At the top of the cylinder: Reading the top of the liquid meniscus overestimates the volume and can result in administering an incorrect dose. Accuracy requires aligning the eye with the meniscus base.
Correct Answer is B
Explanation
A. Monitor the client's respiratory rate every 15 minutes: Frequent respiratory monitoring is essential for opioids or medications with sedative effects, but it does not directly measure pain relief or effectiveness of the analgesic.
B. Ask the client to rate their pain on a scale from 0 to 10 after one hour: Evaluating pain using a standardized numeric scale allows the nurse to determine the medication’s effectiveness. Oral analgesics typically take about 30–60 minutes to achieve peak effect, making this timing appropriate for reassessment.
C. Schedule a follow-up assessment for the next day: Waiting until the next day would delay recognition of inadequate pain control or need for intervention. Pain assessment should be timely to ensure client comfort and safety.
D. Immediately contact the provider for additional prescriptions: Contacting the provider is premature before evaluating whether the administered medication was effective. Reassessment guides appropriate follow-up action.
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