The nurse is reviewing the intake and output record from the previous 8 hours for an infant admitted with dehydration.
The nurse also reviews the most recent lab results in the chart.
Based on the information in the chart, what does the nurse determine about this patient during the shift?
Option A
Option B
Option C
Option D
The Correct Answer is A
Choice A rationale
Dehydration in infants can be a serious medical concern if not addressed quickly. It can be caused by various factors such as vomiting or diarrhea, or if the baby is not nursing well. The most common signs of dehydration in babies include concentrated urine that looks very dark yellow or orange, constipation, dry lips, dry mouth, dry mucous membranes, excessive sleepiness, irritability, less than six wet diapers in a 24-hour period, no interest in taking a bottle or breastfeeding, no tears when crying, paleness, sunken fontanelle (soft spot) on their head, and wrinkled skin. If the nurse observes these signs and symptoms in the infant, along with the intake and output record from the previous 8 hours, the nurse might determine that the patient is dehydrated during the shift.
Choice B rationale
If the infant shows signs of improvement such as increased urine output, normal skin turgor, moist mucous membranes, and the infant is alert and active, then the nurse might determine that the patient is improving as anticipated. However, without specific details about the infant’s condition, it’s difficult to definitively say that this is the case.
Choice C rationale
Fluid volume excess, also known as fluid overload, occurs when the body has too much water and electrolytes. Symptoms can include swelling in the hands, feet, ankles, or abdomen, weight gain, high blood pressure, and shortness of breath. If the nurse observes these symptoms in the infant, along with the intake and output record from the previous 8 hours, the nurse might
determine that the patient has fluid volume excess. However, given the information provided, this does not seem to be the most likely scenario.
Choice D rationale
If the infant’s vital signs are stable, the infant is alert and active, and there are no significant changes in the infant’s condition, the nurse might determine that the patient’s condition is stable. However, without specific details about the infant’s condition, it’s difficult to definitively say that this is the case.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","D"]
Explanation
Choice A rationale
After a tonsillectomy, it’s crucial to manage the child’s pain effectively. Pain can deter children from eating or drinking, which can lead to dehydration. Therefore, ensuring that the child’s pain is well managed is an essential part of post-operative care.
Choice B rationale
Mild ear pain or foul breath after surgery are common symptoms following a tonsillectomy. These symptoms do not necessarily indicate a problem, but they should be monitored. If these symptoms persist or worsen, it may be necessary to seek medical attention.
Choice C rationale
After a tonsillectomy, it’s recommended that the child eat soft foods for the first few days. Crunchy foods can irritate the throat and delay healing. Therefore, avoiding crunchy foods initially is an important part of post-operative care.
Choice D rationale
Following a tonsillectomy, it’s normal for the child to form scabs on their tonsils as they heal. This is a normal part of the healing process and is not a cause for concern.
Correct Answer is D
Explanation
Choice A rationale
Tobramycin is an antibiotic often used in people with cystic fibrosis to combat bacterial infections in the lungs. However, it is not typically administered prior to vest therapy.
Choice B rationale
Dornase alfa is a medication used to thin the thick, sticky mucus in the lungs of people with cystic fibrosis. While it can help improve lung function and reduce the risk of respiratory infections, it is not typically administered prior to vest therapy.
Choice C rationale
Flutter valve therapy is another method used to clear mucus from the lungs. It is not typically administered after vest therapy.
Choice D rationale
Albuterol is a bronchodilator that relaxes muscles in the airways and increases air flow to the lungs. Administering albuterol prior to vest therapy can help open the airways and make the therapy more effective.
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