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 D
Explanation
Choice A rationale
Restlessness, bilateral wheezes, and poor feeding are concerning symptoms in a child. Restlessness can indicate discomfort or distress. Bilateral wheezes can suggest an airway obstruction or inflammation, often seen in conditions like asthma. Poor feeding can be a sign of general illness or specific conditions like gastrointestinal disorders. However, these symptoms, while concerning, are not as immediately threatening as the symptoms described in choice D12.
Choice B rationale
Sitting up, coarse breath sounds, coughing, and restlessness are also concerning symptoms. Coarse breath sounds and coughing can indicate a respiratory infection or other lung condition. Restlessness can again indicate discomfort or distress. However, these symptoms are not as immediately threatening as the symptoms described in choice D12.
Choice C rationale
Not eating well and increased respiratory effort are signs of potential illness. Not eating well can lead to malnutrition and weakened immunity, making the child more susceptible to infections and slowing recovery. Increased respiratory effort can be a sign of respiratory distress, which could be due to conditions like pneumonia or asthma. However, these symptoms are not as immediately threatening as the symptoms described in choice D12.
Choice D rationale
A toddler in the tripod position (sitting up and leaning forward, using the arms to support the upper body), with diminished breath sounds and grunting, is showing signs of severe respiratory distress. The tripod position is often used instinctively to maximize airway patency and ease breathing. Diminished breath sounds can indicate significant airway obstruction or lung disease. Grunting is a sign of increased work of breathing and is often seen in conditions like pneumonia or severe asthma. These symptoms together suggest that the child may be in respiratory failure, which is a life-threatening emergency requiring immediate medical attention.
Correct Answer is ["B","C","D"]
Explanation
Choice A rationale
While maintaining a cool, dry environment can be comfortable for the child, it is not specifically related to tracheostomy care. Humidity can actually be beneficial for a child with a tracheostomy, as it helps to keep the airway moist and prevent mucus from becoming too thick.
Choice B rationale
Having emergency tracheostomy equipment available at all times is crucial. This should include a spare tracheostomy tube of the same size and one size smaller, suction equipment, and a bag-valve-mask device. In case of a problem with the tracheostomy tube (such as blockage or accidental dislodgement), it is important to have the necessary equipment immediately available.
Choice C rationale
Changing the tracheostomy tube at the ordered frequency is important to prevent blockage and infection. The frequency will depend on various factors, including the type of tracheostomy tube and the child’s specific condition.
Choice D rationale
Monitoring the thickness and color of secretions can help to detect infections or other complications. Changes in secretions can be an early sign of problems such as tracheitis or pneumonia.
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