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
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Providing guidance on incentive spirometry requires specialized knowledge and skill that should be provided by a licensed healthcare provider, such as a nurse.
B. A client who had a myocardial infarction 3 days ago and reports chest discomfort requires ongoing assessment and monitoring by a licensed healthcare provider, such as a nurse, due to the potential for cardiac complications.
C. Assisting a client who had a stroke 2 days ago and needs help toileting is a task that can be safely delegated to an assistive personnel, as long as the client's condition is stable and the assistive personnel has been trained in providing basic care.
D. Providing a drink to a client who has awoken following a bronchoscopy may require assessment and monitoring for potential complications, such as aspiration or respiratory distress, which should be provided by a licensed healthcare provider, such as a nurse.
Correct Answer is D
Explanation
A. Routine activities such as daily baths are not typically pertinent information to include in a change-of-shift report unless they have a significant impact on the client's condition or care.
B. While vomiting after surgery may be noteworthy, the timing and amount of emesis
immediately after surgery may not be relevant to the client's current condition, especially if it was an isolated incident.
C. Flushing the IV with normal saline is a routine nursing intervention and may not be necessary to report unless there were specific concerns or complications related to the IV.
D. Pain relief is an important aspect of postoperative care and should be included in the report to ensure continuity of care and appropriate pain management for the client.
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