A nurse is caring for a 3-month-old infant who has gastroenteritis and is receiving monitoring for dehydration. For which of the following findings should the nurse monitor?
Bulging fontanel
Weight loss
Distended jugular vein
Bradycardia
The Correct Answer is B
A. Bulging fontanel: A bulging fontanel typically indicates increased intracranial pressure, not dehydration. In dehydration, the fontanel is more likely to appear sunken in infants, making this an incorrect finding to monitor for fluid loss.
B. Weight loss: Weight loss is a key indicator of fluid loss in infants. Monitoring daily weight provides an objective measure of dehydration severity and effectiveness of rehydration interventions, making it a critical finding for the nurse to track.
C. Distended jugular vein: Jugular vein distention is associated with fluid overload or cardiac issues, not dehydration. This finding would be unlikely in a 3-month-old infant with gastroenteritis.
D. Bradycardia: Dehydration in infants typically presents with tachycardia as the body compensates for decreased fluid volume. Bradycardia is not a common sign of dehydration and may indicate another underlying condition.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["1.5"]
Explanation
Calculation:
- Identify the ordered dose and available concentration
Ordered Dose: 30 mg
Available Concentration: 100 mg/5 mL
- Calculate the volume to administer
Volume to administer = (Ordered Dose ÷ Concentration) × Volume of Concentration
Volume to administer = (30 ÷ 100) × 5
Volume to administer = 0.3 × 5
Volume to administer = 1.5 mL
Correct Answer is C
Explanation
A. "You should eat hot foods to reduce your sense of fullness during a meal.": Hot foods can actually increase the feeling of fullness and may lead to early satiety, which is not ideal for clients with COPD who need to maintain adequate nutrition and energy intake.
B. "While eating you should drink liquids frequently.": Drinking large amounts of liquids during meals can cause early satiety and reduce overall caloric intake. Clients with COPD are encouraged to drink fluids between meals rather than during meals to avoid feeling too full.
C. "During meals, you should eat foods with a high-calorie content first.": Prioritizing high-calorie, nutrient-dense foods ensures the client consumes adequate energy before fatigue or fullness sets in. This strategy helps prevent unintentional weight loss and supports overall respiratory function in COPD.
D. "Lunch should be your largest meal of the day.": For clients with COPD, smaller, more frequent meals are recommended to prevent dyspnea and fatigue during eating. Large meals can exacerbate breathing difficulties, so meal size should be balanced throughout the day.
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