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

A. Raise the side rails up when the client is in bed: Full side rails can increase the risk of entrapment and injury for clients with dementia. They are not recommended as a routine safety measure unless individually assessed and ordered.

B. Place the bedside table at the foot of the bed: Placing furniture at the foot of the bed can create obstacles and increase the risk of trips and falls. The environment should be arranged to allow safe, unobstructed mobility.

C. Keep the television on during the night: Continuous noise, such as a TV, can cause agitation or confusion in clients with dementia, increasing the risk of disorientation and injury. Quiet, calming environments are preferred.

D. Assist the client to the toilet frequently: Clients with dementia are at increased risk for falls due to urgency, confusion, or impaired mobility. Frequent toileting assistance reduces the risk of incontinence-related hazards and falls, promoting safety and dignity.

A. "Keep objects away from your center of gravity while lifting." B. "Keep your feet together to provide a tight base of support." C. "Tighten abdominal muscles to improve balance." D. "Bend at the waist when lifting objects from the floor."

Correct Answer is C

Explanation

A. "Keep objects away from your center of gravity while lifting.": Lifting objects away from the body increases strain on the back and risks injury. Objects should be kept close to the body to reduce musculoskeletal stress.

B. "Keep your feet together to provide a tight base of support.": A narrow stance decreases stability and increases the risk of losing balance. Proper lifting requires a wide, stable base with feet shoulder-width apart.

C. "Tighten abdominal muscles to improve balance.": Engaging the core stabilizes the spine, maintains proper posture, and helps prevent back injuries during lifting. This is an important ergonomic technique.

D. "Bend at the waist when lifting objects from the floor.": Bending at the waist places excessive strain on the lower back. Proper lifting technique involves bending at the knees and hips while keeping the back straight.

View Question and Answer

A nursery nurse is attending the birth of a post-term infant.

Exhibits

Drag words from the choices below to fill in each blank in the following sentence.

Upon review of the medical record, the nurse should determine the infant newborn is at risk for developing

and .

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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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A nurse in a long-term care facility is admitting a client who has dementia. Which of the following actions should the nurse take to reduce the risk for client injury?

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Explanation

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