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 B
Explanation
A. Instruct the client to flex the right knee every 30 min: After a femoral cardiac catheterization, the affected leg should remain straight to prevent bleeding or hematoma formation. Flexing the knee could disrupt hemostasis at the insertion site.
B. Assess the client's peripheral pulses every 15 min: Frequent monitoring of peripheral pulses ensures early detection of vascular complications such as thrombosis, occlusion, or impaired circulation in the affected limb.
C. Change the client's dressing 4 hr following the procedure: The initial dressing is typically left intact for several hours or until bleeding is controlled. Early dressing changes are unnecessary and may increase infection risk.
D. Elevate the head of the client's bed to 45°: Elevating the head of the bed can increase pressure on the femoral insertion site and risk bleeding. The client’s bed is usually kept flat or slightly elevated according to provider orders until hemostasis is confirmed.
Correct Answer is ["A","B","C","E"]
Explanation
A. ABG results: pH 7.32 (acidosis), HCO₃⁻ 18 mEq/L (low), PaO₂ 68 mm Hg, SaO₂ 90%. Indicates metabolic acidosis with hypoxemia. This is a significant abnormality needing prompt attention.
B. Amylase results: Elevated amylase is a hallmark of acute pancreatitis and confirms the suspected diagnosis.
C. Temperature: Fever with pancreatitis can signal systemic inflammatory response or infection, requires provider notification.
D. Hematocrit level: 42%, within the normal range (female 38–47%, male 42–52%).
E. Pain report: Severe abdominal pain 8/10, persistent >24 hours. Pancreatitis pain requires provider management (often opioids, supportive care).
F. Glucose level: 108 mg/dL is within normal limits (70–110). It is not concerning at this time.
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