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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

Answer and Explanation

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.

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Free Nursing Study Resources

Correct Answer is A

Explanation

It is essential for the nurse to maintain a non-judgmental and supportive attitude when caring for clients with STIs, including genital herpes. Assuring the client of confidentiality helps to create a safe and trusting environment, encouraging open communication about the client's concerns and experiences.

This approach promotes the client's well-being and allows for effective education and support regarding STI prevention, transmission, and management.

A. Use firmness and direct the client to sit for awhile. B. Suggest to the client that he take a walk. C. Move the client to a quiet place on the unit. D. Encourage the client to use the punching bag

Correct Answer is C

Explanation

Delusions and loss of control can be distressing for the client and potentially disruptive to the unit environment. Moving the client to a quiet place helps create a calm and less stimulating environment, which can help reduce agitation and promote a sense of safety and security.

Using firmness and directing the client to sit for a while may escalate the situation and increase the client's distress. It is important to approach the client with empathy and provide a supportive environment rather than exerting control through firmness.

Suggesting the client take a walk or encouraging the client to use a punching bag may not be appropriate if the client is already displaying signs of agitation and losing control. These interventions may not address the underlying causes of the delusions and could potentially worsen the situation.

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Naxlex Comprehensive Predictor Exams

The nurse is caring for a client with the sexually transmitted infection (STI) genital herpes. The client reports having sex with multiple partners. Which response should the nurse provide

Correct Answer is A

Explanation

The nurse notices that a male client is particularly delusional one afternoon. He begins to pace the floor and appears to be losing control of himself. Which intervention is best for the nurse to implement?

Correct Answer is C

Explanation

A client with a history of lung cancer reluctantly comes to the clinic because of persistent hoarseness and a chronic cough. The client's respirations are labored when speaking and the capillary refill is 3 seconds. Which additional finding warrants intervention by the nurse?

Exhibits here Review H and P. What factors are important in determining the level of hypoxemia that the child may have experienced during the submersion? Select all that apply.

A client with unilateral hearing loss is admitted for a scheduled surgery. Which technique should the nurse use to provide education about pain relief options?

A client with cancer is admitted to the oncology unit and tells the nurse that he is in the hospital for palliative care measures. The nurse notes that the client's admission prescriptions include radiation therapy. Which action should the nurse implement?

An older woman who has difficulty hearing is being discharged from day surgery following a cataract extraction and lens implantation. Which intervention is most important for the nurse to implement to help ensure the client's compliance with self-care?

When performing suctioning for a client with a tracheostomy, which action should the nurse include?