A nurse is caring for an infant who is being treated for dehydration. Which of the following findings indicates the treatment is effective?

Flat anterior fontanel

Oliguria

Oral intake of 4 oz every 3 hr

Capillary refill 4 seconds

Answer and Explanation

The Correct Answer is C

A. A flat anterior fontanel can indicate dehydration in infants, so this finding does not indicate effective treatment.

B. Oliguria, or decreased urine output, is a sign of dehydration and would not indicate effective treatment.

C. Oral intake of 4 oz every 3 hours indicates that the infant is able to drink fluids and is likely rehydrated, indicating effective treatment.

D. A capillary refill of 4 seconds is prolonged and can indicate poor perfusion, which is not indicative of effective treatment for dehydration.

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Correct Answer is D

Explanation

A. A blood pressure of 94/68 mm Hg is within the normal range for a 7-year-old child and may indicate compensated dehydration rather than severe dehydration.

B. A urinary output of 30 mL/hr is insufficient and may indicate dehydration, but it does not specifically indicate severe dehydration.

C. A respiratory rate of 24/min is within the normal range for a 7-year-old child and is not specifically indicative of severe dehydration.

D. Tachycardia (heart rate >100 beats per minute) is a common finding in severe dehydration as the body attempts to compensate for decreased blood volume by increasing heart rate.

A. Insert the catheter until a flow of urine begins. B. Attach prefilled syringe to indwelling catheter inflation hub. C. Lubricate the catheter and place fenestrated drape over perineum. D. Apply sterile gloves and place cleansing balls in antiseptic solution. E. Cleanse the meatus with the dominant hand in a downward motion.

Correct Answer is D,C,E,A,B

Explanation

D. Apply sterile gloves and place cleansing balls in antiseptic solution.

C. Lubricate the catheter and place fenestrated drape over perineum.

E. Cleanse the meatus with the dominant hand in a downward motion.

A. Insert the catheter until a flow of urine begins.

B. Attach prefilled syringe to indwelling catheter inflation hub.

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A nurse is caring for an infant who is being treated for dehydration. Which of the following findings indicates the treatment is effective?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a 7-year-old child who has severe dehydration. Which of the following findings should the nurse expect?

Correct Answer is D

Explanation

A nurse is preparing to insert an indwelling urinary catheter for a female client. Identify the sequence of actions the nurse should take. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

Correct Answer is D,C,E,A,B

Explanation

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