When assessing an infant with moderate dehydration, a nurse would expect which assessment findings?
Fever and hypertension.
Increased specific gravity.
Tachypnea and tachycardia.
Bulging posterior fontanel.
The Correct Answer is C
Choice A rationale:
Fever and hypertension are not typical findings in moderate dehydration. Dehydration often leads to hypotension rather than hypertension, and fever is not a direct consequence of dehydration.
Choice B rationale:
Increased specific gravity can be a sign of dehydration, but it is not as specific or sensitive as tachypnea (rapid breathing) and tachycardia (elevated heart rate), which occur due to the body's compensatory mechanisms in response to dehydration.
Choice C rationale:
Tachypnea and tachycardia are key indicators of moderate dehydration in infants. The body tries to maintain perfusion by increasing the heart rate and respiratory rate. These signs are more reliable indicators of dehydration than specific gravity or fever.
Choice D rationale:
Bulging posterior fontanel is not a typical finding in dehydration. A sunken fontanel might be more indicative of dehydration, as fluid shifts from the intracellular to the extracellular space.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct answer is choice A. Takes a bubble bath every day.
Choice A rationale:
Bubble baths can cause urinary tract infections (UTIs) in children. The soap and bubbles can irritate the child’s privates, leading to discomfort and potentially contributing to the development of a UTI. It’s particularly true for young girls, as exposure to soap and bubbles can hurt their privates, leaving them itchy and uncomfortable. While not the most common cause, bubble baths have been associated with UTIs due to the irritation they can cause.
Choice B rationale:
While handwashing is crucial for preventing the spread of germs, there is less direct evidence linking the lack of handwashing after toileting to UTIs. However, good hygiene practices, including handwashing, are generally recommended to reduce the risk of infections.
Choice C rationale:
Carbonated beverages have been associated with bladder irritation and UTIs in some cases. They can cause problems for individuals with interstitial cystitis, bladder stones, and UTIs due to the carbonic acid they contain. However, the link between carbonated beverages and UTIs is not as direct as that of bubble baths.
Choice D rationale:
Wiping the perineal area from front to back after toileting is actually a recommended practice to prevent UTIs. It helps to prevent bacteria from the stool from contaminating the urethra and bladder, which can lead to an infection. Therefore, this choice is unlikely to be related to the client’s UTI.
In conclusion, the most likely data related to the client’s urinary tract infection is the daily bubble baths, as they can directly irritate the urinary tract and create conditions conducive to a UTI.
Correct Answer is B
Explanation
Choice A rationale:
Pancreatic enzymes are used to aid in digestion and are not known to interact significantly with serum creatinine levels. Therefore, they are unlikely to be contraindicated based solely on an elevated serum creatinine level.
Choice B rationale:
Gentamicin is an aminoglycoside antibiotic that is primarily eliminated by the kidneys. Elevated serum creatinine levels indicate potential renal impairment, which could lead to reduced drug clearance and an increased risk of gentamicin toxicity, including nephrotoxicity and ototoxicity. Consulting the health care provider before administering gentamicin is important to ensure the appropriateness of the medication dosage and regimen.
Choice C rationale:
Albuterol is a bronchodilator commonly used to treat respiratory conditions. Serum creatinine levels are not directly related to albuterol administration. It is unlikely that an elevated serum creatinine level would significantly affect the administration of albuterol.
Choice D rationale:
Carbenicillin is an antibiotic that is excreted through the kidneys. While renal function may impact the dosing of carbenicillin, an elevated serum creatinine level alone may not necessarily warrant consultation with the health care provider. Other factors such as the severity of renal impairment and the patient's overall condition would need to be considered.
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