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."
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. "A living will is a document that includes my wishes about health care decisions.": A living will is an advance directive that specifies a client’s preferences for medical treatment in situations where they are unable to communicate.
B. "My partner needs to be present as a witness when I sign a living will.": Witness requirements vary by state, and typically a neutral adult, not necessarily a partner, must witness the signing.
C. "My provider will make my health care decisions if I complete advance directives.": Advance directives are intended to communicate the client’s own wishes, not delegate decision-making solely to the provider. The provider’s role is to follow the client’s documented preferences.
D. "Advance directives outline who inherits my material possessions in the event of my death.": Inheritance is addressed in a will, not advance directives. Advance directives focus exclusively on medical and end-of-life care decisions.
Correct Answer is A
Explanation
Rationale:
A. Maintain the irrigation solution rate: Pink-tinged urine is expected in the early hours after a TURP due to residual bleeding from the surgical site. The nurse should continue the current irrigation rate to prevent clot formation and maintain catheter patency.
B. Warm the irrigation solution: Warming the solution is not required for bladder irrigation and does not address the normal postoperative finding of pink-tinged urine. It also does not play a role in preventing clot formation.
C. Perform the Credé's maneuver: This technique, involving manual bladder compression, is not appropriate for a client with a continuous bladder irrigation and indwelling catheter in place. It could cause injury or disrupt the surgical site.
D. Replace the indwelling urinary catheter: There is no indication of catheter blockage or malfunction in this scenario. Replacing the catheter unnecessarily increases infection risk and could damage the urethra or surgical area.
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