A nurse in an urgent care clinic is caring for an infant who presents with vomiting, diarrhea, and decreased oral intake. Which of the following manifestations should the nurse expect?
Bulging anterior fontanel
Decreased temperature
Hypertension
Oliguria
The Correct Answer is D
A. Bulging anterior fontanel. A bulging fontanel is associated with increased intracranial pressure, not dehydration. Dehydration is more likely to cause a sunken fontanel.
B. Decreased temperature. Dehydrated infants typically exhibit normal or elevated temperatures, especially if they have an underlying infection or fever. A decreased temperature is not a common sign of dehydration.
C. Hypertension. Dehydration more commonly leads to hypotension or normal blood pressure, depending on severity. Hypertension is not an expected finding in an infant with fluid volume loss.
D. Oliguria. Decreased urine output (oliguria) is a classic and expected sign of dehydration in infants. It indicates the kidneys are conserving fluid due to inadequate intake and fluid loss from vomiting and diarrhea.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Beneficence. This principle refers to acting in the best interest of the client by promoting their well-being and providing comfort. Sitting with a grieving client to offer emotional support is an act of kindness and compassion, aligning with beneficence.
B. Autonomy. Autonomy involves respecting the client’s right to make decisions about their own care. While important, it is not the primary ethical principle demonstrated in this situation.
C. Fidelity. Fidelity refers to keeping promises and maintaining trust in the nurse-client relationship. While the nurse is being supportive, the act described does not specifically demonstrate the principle of fidelity.
D. Veracity. Veracity involves telling the truth and being honest with clients. It is not the relevant principle in this context, as the focus is on emotional support rather than the communication of factual information.
Correct Answer is A
Explanation
A. Wear loose-fitting clothing. After ICD implantation, the site may be sore or swollen, and tight clothing can cause irritation or pressure. Loose-fitting clothes help protect the incision and device, reducing discomfort and risk of complications.
B. Return in two weeks for a follow-up MRI. Most implantable cardioverter/defibrillators are not MRI-compatible unless specifically labeled as such. MRI exposure can interfere with device function and is generally avoided unless approved by a cardiologist.
C. Expect to have a rapid pulse rate for the first few weeks. The purpose of an ICD is to monitor and correct life-threatening arrhythmias, not to increase the heart rate. A rapid pulse is not expected and may indicate a complication requiring immediate evaluation.
D. Resume tub baths and swimming after 24 hr. Immersing the incision site in water within the first few weeks post-op increases the risk of infection. The client should avoid soaking the incision until it is fully healed, typically 1 to 2 weeks post-procedure.
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