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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Sputum culture is used to diagnose active tuberculosis but is not typically used for routine screening of asymptomatic individuals.
B. Chest x-ray can detect active tuberculosis or its complications but is not typically used for routine screening of asymptomatic individuals.
C. QuantiFERON-TB Gold blood analysis is a blood test that detects the presence of tuberculosis infection but is not typically used for routine screening of asymptomatic individuals.
D. The Mantoux test, also known as the tuberculin skin test (TST), is commonly used for routine screening of tuberculosis infection in asymptomatic individuals, including new employees in healthcare settings.
Correct Answer is A
Explanation
A.
A. Clear fluid drainage from the nares, especially if it is continuous or persistent, may indicate a cerebrospinal fluid (CSF) leak, which can occur with a skull fracture.
B. Pain around the eyes is more commonly associated with a nasal fracture or orbital fracture, rather than a skull fracture.
C. Dried blood in the mouth may indicate nasal bleeding but does not necessarily indicate a skull fracture.
D. Mandibular asymmetry may indicate a jaw fracture or injury but is not typically associated with a skull fracture.
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