The nurse is caring for a 10-month old client with dehydration. What method would the nurse use to measure urine output?
Perform an in/out catheterization
Insert a Foley catheter
Collect the client's urine in a cup
Count the number of wet diapers
The Correct Answer is D
Choice A reason: Performing an in/out catheterization is not a suitable method to measure urine output for a 10-month old client with dehydration. An in/out catheterization is a procedure where a catheter is inserted into the bladder through the urethra, and the urine is drained and measured. This method is invasive, painful, and carries the risk of infection and trauma. It is usually reserved for clients who have urinary retention or obstruction, or who need a sterile urine sample.
Choice B reason: Inserting a Foley catheter is also not an appropriate method to measure urine output for a 10-month old client with dehydration. A Foley catheter is a type of catheter that stays in the bladder and drains the urine into a collection bag. This method is also invasive, painful, and carries the risk of infection and trauma. It is usually used for clients who have urinary incontinence, surgery, or long-term bed rest.
Choice C reason: Collecting the client's urine in a cup is not a feasible method to measure urine output for a 10-month old client with dehydration. A cup is not a reliable or accurate device to collect and measure urine, especially for a young child who may not be toilet trained or cooperative. It is also difficult to ensure that all the urine is collected in the cup, and that the cup is not contaminated by other fluids or substances.
Choice D reason: Counting the number of wet diapers is the best method to measure urine output for a 10-month old client with dehydration. This method is non-invasive, simple, and practical. It can provide an estimate of the urine volume and frequency, and indicate the hydration status of the child. The nurse should weigh the diapers before and after use, and record the difference in grams. One gram of weight equals one milliliter of urine. The nurse should also observe the color, odor, and concentration of the urine. The normal urine output for a child is 1 to 2 mL/kg/hour.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: This statement is false. Drinking more fluids in the late evening can cause nocturia, which is the need to urinate frequently at night. This can disrupt the sleep cycle and increase the risk of falls.
Choice B reason: This statement is true. Dry mouth is a sign of dehydration and indicates the need for more fluid intake. Older adults may have reduced thirst sensation and may not drink enough fluids throughout the day.
Choice C reason: This statement is false. Caffeine is a diuretic, which means it increases urine output and can worsen dehydration. Confusion is a symptom of dehydration and requires immediate medical attention.
Choice D reason: This statement is false. Feeling full is not a reliable indicator of hydration status. Older adults may have decreased appetite and gastric motility, which can make them feel full even when they are dehydrated.
Correct Answer is ["A","E","F"]
Explanation
Choice A reason: This statement is true. Distended neck veins are a sign of fluid volume overload, as they indicate increased central venous pressure and right-sided heart failure.
Choice B reason: This statement is false. Hypotension is a sign of fluid volume deficit, not fluid volume overload. Hypotension occurs when the blood pressure is too low to perfuse the vital organs.
Choice C reason: This statement is false. Increased serum osmolality is a sign of fluid volume deficit, not fluid volume overload. Increased serum osmolality occurs when the blood concentration of solutes, such as sodium and glucose, is too high due to fluid loss.
Choice D reason: This statement is false. Dry oral mucosa is a sign of fluid volume deficit, not fluid volume overload. Dry oral mucosa occurs when the oral cavity is dehydrated due to fluid loss.
Choice E reason: This statement is true. Decreased urine specific gravity is a sign of fluid volume overload, as it indicates diluted urine and impaired kidney function.
Choice F reason: This statement is true. Weight gain is a sign of fluid volume overload, as it indicates fluid retention and edema.
Choice G reason: This statement is false. Sunken anterior fontanelle is a sign of fluid volume deficit, not fluid volume overload. Sunken anterior fontanelle occurs when the soft spot on the baby's head is depressed due to fluid loss.
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