This is an 11-month-old male with a 2-day history of fussiness, increased nasal secretions, and cough. The baby is 24.3 lb. (11 kg). He was born at 34 weeks gestation and spent several weeks in the neonatal intensive care unit for poor feeding.
He is currently up to date on vaccinations and is meeting appropriate developmental milestones. The parents deny that he takes any medications at home.
Review H and P and flow sheet.
Select which assessment findings indicate that the baby has an increased fluid requirement. Select all that apply.
Temperature 103 °F (39.4 °C)
Blood pressure 89/51 mmHg
Respiratory rate 55 breaths/min
Copious, clear secretions from both nostrils
Oxygen saturation 95%
Wet diaper with 12 mL of urine
Heart rate 159 bpm
Correct Answer : A,C,D,E
Fever increases fluid loss through perspiration.
Increased respiratory rate can lead to increased fluid loss through evaporation. Increased nasal secretions can result in fluid loss.
High oxygen flow can cause drying of the mucous membranes and increase fluid requirements.
The following findings do not necessarily indicate increased fluid requirements: Blood pressure alone does not indicate increased fluid requirements.
Oxygen saturation within the normal range does not indicate increased fluid requirements.
Although urine output is important to assess hydration status, 12 mL of urine may not necessarily indicate increased fluid requirements.
Heart rate alone does not indicate increased fluid requirements.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The correct answer is choice c. Inform the client that gradual tapering must be used to discontinue the medication.
Choice A rationale:
While discussing medication side effects with the healthcare provider is important, it does not address the immediate concern of discontinuing the medication safely. The nurse should provide guidance on the proper discontinuation process.
Choice B rationale:
Telling the client that side effects will most likely dissipate over time may not be accurate for all individuals and does not address the client’s desire to stop the medication.
Choice C rationale:
Informing the client that gradual tapering must be used to discontinue the medication is crucial. Abruptly stopping antidepressants can lead to withdrawal symptoms and a potential relapse of depression.
Choice D rationale:
Reminding the client that feeling better is the therapeutic effect of the medication is true, but it does not address the client’s concern about discontinuing the medication safely.
Correct Answer is A
Explanation
To monitor for adverse effects from prasugrel, a platelet inhibitor, the nurse should prioritize assessing for bleeding or abnormal bleeding tendencies. Therefore, observing the color of urine is the most important assessment among the options provided.
Changes in urine color, such as the presence of blood or dark-colored urine, can indicate internal bleeding or bleeding in the urinary tract, which can be a potential adverse effect of platelet inhibitors. It is crucial to monitor for signs of bleeding to ensure the client's safety and intervene promptly if necessary.
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