A nurse is assessing an infant who has water intoxication. Which of the following findings should the nurse expect?

Generalized edema

Elevated urine specific gravity

Thready pulse

Increased hematocrit

Answer and Explanation

The Correct Answer is C

A. Water intoxication can lead to dilutional hyponatremia, which may result in fluid shifting into cells, causing cellular swelling and potentially cerebral edema, but generalized edema is not typically associated with water intoxication.

B. Water intoxication leads to dilution of electrolytes, including sodium, which results in decreased urine specific gravity rather than elevated.

C. Thready pulse is a common finding in water intoxication due to electrolyte imbalances and hemodilution.

D. Increased hematocrit is not typically associated with water intoxication; rather, it may indicate dehydration or hemoconcentration.

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Correct Answer is D

Explanation

A. Detaching the needle from the syringe before discarding it increases the risk of needle-stick injuries. Needles should be disposed of as one unit to minimize the risk of injury.

B. Broken glass should be disposed of in a puncture-proof container to prevent injuries. Placing it directly in a wastebasket increases the risk of puncture injuries to individuals handling the waste.

C. Recapping needles increases the risk of needle-stick injuries. Needles should not be recapped after use unless there is no safer alternative. Instead, they should be disposed of as one unit.

D. Lancets, needles, and other sharp objects should be placed in puncture-proof containers immediately after use to prevent injuries. This practice helps ensure the safety of healthcare workers and others who handle waste.

A. Insert an indwelling catheter if the client has not voided in 3 hr. B. Obtain the abdominal girth now and every 4 hr. C. Assess and document the level of consciousness every hour. D. Measure the amount of gastric drainage every 2 hr. E. None F. None

Correct Answer is A

Explanation

A. Inserting an indwelling urinary catheter is within the scope of practice of an LPN and is an appropriate task to delegate.
B. Measuring abdominal girth involves assessment of ascites progression, which requires the nurse’s judgment and should not be delegated.
C. Assessing and documenting the client’s level of consciousness requires critical nursing judgment and must be performed by the RN.
D. Measuring gastric drainage every 2 hr is an appropriate task for an AP, not specifically requiring an LPN.

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A nurse is assessing an infant who has water intoxication. Which of the following findings should the nurse expect?

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Naxlex Comprehensive Predictor Exams

A nurse is following protocol for preventing puncture injuries. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

A nurse delegates tasks to a licensed practical nurse (LPN) and an assistive personnel (AP). When admitting a client who is experiencing acute liver failure and who has ascites and an NG tube, which of the following tasks is most appropriate for the nurse to delegate to the LPN?

Correct Answer is A

Explanation

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