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 D
Explanation
A. Allow the client's partner to translate: Family members should not serve as interpreters due to concerns about accuracy, confidentiality, and potential bias in sensitive health information.
B. Ask a nursing student who speaks the same language as the client to translate: Using untrained personnel, including students, is discouraged because they may lack professional interpreting skills and could miscommunicate critical health information.
C. Have the client's child translate: Children are not appropriate interpreters due to their limited language skills, emotional immaturity, and potential to misinterpret medical information.
D. Request a female interpreter through the facility: A professional medical interpreter ensures accurate, confidential communication, respects cultural and gender preferences, and is the safest approach for gathering admission data, particularly regarding sensitive postpartum issues.
Correct Answer is D
Explanation
Rationale:
A. Obtain filterless IV tubing: Blood transfusions require specialized IV tubing with an in-line filter to remove clots and debris. Using filterless tubing would increase the risk of transfusing particulate matter into the client’s bloodstream.
B. Place the blood in a warmer for 1 hr: Blood should only be warmed if specifically prescribed and done using an approved device immediately before administration. Prolonged warming increases the risk of bacterial growth and hemolysis.
C. Use a 24-gauge IV catheter: Packed RBCs should be administered through a larger-bore catheter (typically 18–20 gauge) to allow adequate flow and prevent hemolysis. A 24-gauge catheter is too small for efficient transfusion.
D. Prime IV tubing with 0.9% sodium chloride: Normal saline is the only compatible solution for priming and administering blood products. It prevents clotting and hemolysis while ensuring that the blood flows freely without interacting with other IV solutions.
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