A nurse is caring for an infant who has rotavirus. Which of the following findings indicates that the infant is moderately dehydrated?
Respiratory rate 28/min
Capillary refill 1 second
Weight loss 7%
Bradycardia
The Correct Answer is A
A. A respiratory rate of 28 breaths per minute indicates increased respiratory effort, which can be a sign of moderate dehydration. The infant may be trying to compensate for fluid
loss.
B. Capillary refill of 1 second is within the normal range (less than 2 seconds). It is not indicative of moderate dehydration.
C. Weight loss of 7% is a significant amount of weight loss and is indicative of severe dehydration, not moderate dehydration. Moderate dehydration is usually defined as 5- 10% weight loss.
D. Bradycardia (slow heart rate) is not typically associated with dehydration. In fact, tachycardia (fast heart rate) is a more common sign of dehydration.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Jacket restraints are typically used to secure a child's arms during procedures. They are not specifically designed for venipuncture in infants.
B. Elbow restraints are used to secure the child's elbows, often during procedures involving the upper body. They are not typically used for venipuncture.
C. The mummy restraint is specifically designed to secure an infant's arms during venipuncture. It wraps the arms snugly, allowing access to the veins while minimizing movement.
D. Mitten restraints are used to prevent the child from manipulating equipment or accessing areas that should be restricted. They are not designed for venipuncture procedures.
Correct Answer is ["D","E"]
Explanation
A. Maintaining the child in a supine position is not recommended after a tonsillectomy.
The child should be positioned on their side to prevent aspiration.
B. Cranberry juice is acidic and may be irritating to the surgical site. Clear, non-acidic fluids are usually recommended after a tonsillectomy.
C. While coughing should be minimized to prevent irritation to the surgical site, the child should not be discouraged from coughing if needed to clear secretions.
D. Administering an analgesic on a scheduled basis is important for managing pain after a tonsillectomy. This helps to maintain a consistent level of pain control.
E. Observing the child for frequent swallowing is important, as it may indicate bleeding or discomfort. This is a key assessment after a tonsillectomy.
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