A male infant with a 2-day history of fever and diarrhea is brought to the clinic by his mother who tells the nurse that the child refuses to drink anything. The nurse determines that the child has a weak cry with no tears. Which prescription is most important for the nurse to implement?
Infuse normal saline intravenously.
Apply external cooling blanket.
Provide a bottle of electrolyte solution.
Administer an antipyretic rectally.
The Correct Answer is A
A. Infusing normal saline intravenously is crucial as the infant shows signs of dehydration (weak cry, no tears), and intravenous fluids are necessary to restore hydration and electrolyte balance.
B. Applying an external cooling blanket may be necessary to manage fever but does not address the dehydration issue.
C. Providing an electrolyte solution is helpful, but given the infant’s refusal to drink, IV fluids are more immediate and effective.
D. Administering an antipyretic rectally might help manage fever but does not address the dehydration or fluid needs.
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Related Questions
Correct Answer is B
Explanation
A. While reassuring the client about visiting arrangements is supportive, it is not as critical for ensuring continuity of care.
B. Obtaining a detailed report from the transferring nurse is crucial to ensure all relevant information and the client’s wishes are communicated effectively.
C. Providing written information about end-of-life care is helpful but secondary to ensuring accurate communication of the client’s care preferences.
D. Marking the chart is important, but the immediate priority is ensuring the complete and accurate transfer of care information.
Correct Answer is C,D,B,A
Explanation
The unit manager should first note the date and time of the behavior to have a record of the incident. This information is crucial for any follow-up actions and for maintaining accurate documentation. Next, the manager should discuss the issue privately with the UAP to understand the reasons behind their actions and to communicate the importance of following unit protocols. After this discussion, planning for scheduled break times can be implemented, which may prevent future occurrences by providing clear expectations and structure. Lastly, the manager should evaluate the UAP for signs of improvement following these interventions to ensure that the behavior has been corrected and to determine if further action is needed.
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