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.

Answer and Explanation

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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Correct Answer is B

Explanation

A. Measuring urine output is important for monitoring fluid status but does not address the immediate issue of increasing thirst as a sign of DKA.

B. Administering a dose of regular insulin as prescribed is crucial to manage elevated blood glucose levels and prevent or treat DKA.

C. Resuming normal physical activity is not recommended until DKA is managed and blood glucose levels are stabilized.

D. Drinking electrolyte fluids may help with hydration but is not a direct treatment for DKA; insulin therapy is essential to address the underlying issue.

A. Tell the UAP to turn off the amiodarone. B. Evaluate rhythm of client's heat rate. C. Determine regularity of peripheral pulses. D. Restart the IV infusion in another site.

Correct Answer is B

Explanation

A. The UAP should not make medication decisions; only a nurse or healthcare provider should do this after assessment.

B. The nurse should evaluate the client’s heart rhythm to determine the effectiveness of the amiodarone and to assess for any arrhythmias or side effects of the medication.

C. Checking the regularity of peripheral pulses is important but secondary to assessing the heart rhythm directly.

D. Restarting the IV infusion might be necessary if there are issues with the IV site, but the primary concern is the client's cardiac status.

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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?

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Naxlex Comprehensive Predictor Exams

When developing a teaching plan for a client with newly diagnosed type 1 diabetes mellitus, the nurse should explain that an increased thirst is an early sign of diabetic ketoacidosis (DKA). Which action should the nurse instruct the client to implement if this sign of DKA occurs?

Correct Answer is B

Explanation

Correct Answer is B

Explanation

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