A nurse is caring for a 1-month-old infant who has manifestations of severe dehydration and a prescription for parenteral fluid therapy. The guardian asks, "What are the indication that my baby needs an IV?" Which of the following responses should the nurse make?

"Your baby needs an IV because she is breathing slower than normal."

"Your baby needs an IV because her heart rate is decreased."

"Your baby needs an IV because her fontanels are bulging."

"Your baby needs an IV because she is not producing tears."

Answer and Explanation

The Correct Answer is D

Rationale:

A. "Your baby needs an IV because she is breathing slower than normal.": Severe dehydration is more likely to cause tachypnea rather than slower breathing, as the body attempts to compensate for metabolic acidosis.

B. "Your baby needs an IV because her heart rate is decreased.": Severe dehydration in infants usually results in tachycardia due to hypovolemia. A decreased heart rate may indicate impending cardiovascular collapse, which is a late and severe sign.

C. "Your baby needs an IV because her fontanels are bulging.": Bulging fontanels suggest increased intracranial pressure, not dehydration. Dehydration typically causes sunken fontanels due to decreased fluid volume.

D. "Your baby needs an IV because she is not producing tears.": Absence of tears during crying is a classic sign of significant dehydration in infants. This indicates reduced fluid volume and supports the need for IV therapy to restore hydration.

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Correct Answer is D

Explanation

Rationale:

A. Case manager: A case manager coordinates overall care and resources for clients but does not provide direct interventions to improve fine motor skills affected by neuropathy.

B. Physical therapist: Physical therapy focuses on improving gross motor function, strength, balance, and mobility, rather than fine motor activities like buttoning clothes.

C. Social worker: Social workers assist with psychosocial support, community resources, and counseling, but they do not address functional limitations caused by neuropathy.

D. Occupational therapist: Occupational therapy specializes in helping clients perform activities of daily living (ADLs) and can provide adaptive techniques or devices to improve fine motor function, such as buttoning clothes, which is appropriate for this client’s needs.

A. Apply pressure to the lacrimal punctum. B. Place the child in a sitting position. C. Instill the drops of medication. D. Pull the lower eyelid downward.

Correct Answer is B, D, C, A

Explanation

Rationale:

A. Apply pressure to the lacrimal punctum: This step is performed last to prevent systemic absorption of the medication by blocking the nasolacrimal duct. Holding gentle pressure for about 1 minute helps maximize the local effect of the drops.

B. Place the child in a sitting position: Positioning the child upright or with the head slightly tilted back promotes comfort, stability, and proper visualization of the conjunctival sac for accurate drop placement.

C. Instill the drops of medication: Instillation should occur after exposing the conjunctival sac to ensure the medication reaches the target area. The dropper should not touch the eye to prevent contamination.

D. Pull the lower eyelid downward: This creates a conjunctival pocket that holds the medication and allows it to spread evenly over the eye surface without spilling.

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A nurse is caring for a 1-month-old infant who has manifestations of severe dehydration and a prescription for parenteral fluid therapy. The guardian asks, "What are the indication that my baby needs an IV?" Which of the following responses should the nurse make?

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Naxlex Comprehensive Predictor Exams

A home health nurse is caring for a client who reports difficulty buttoning their clothes due to neuropathy. Which of the following referrals should the nurse make for the client?

Correct Answer is D

Explanation

A nurse is preparing to administer eye drops to a school-age child. Identify the actions the nurse should take. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

Correct Answer is B, D, C, A

Explanation

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