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 A

Explanation

A. Discarding opened cans of formula after 24 hours helps prevent bacterial contamination and growth, which can contribute to diarrhea in clients receiving enteral feedings.

B. Extension tubing should be replaced according to institutional policy and manufacturer recommendations, typically every 24 to 48 hours, but it is not directly related to diarrhea management.

C. Irrigating the tubing with warm water is not a standard practice for managing diarrhea in clients receiving enteral feedings and may disrupt the client's fluid and electrolyte balance.

D. Increasing the infusion rate of enteral feedings is not indicated for managing diarrhea and may exacerbate the problem by overwhelming the client's gastrointestinal tract. The rate of enteral feeding should be adjusted based on the client's nutritional needs and tolerance, as determined by the healthcare provider.

A. Sputum culture B. Chest x-ray C. QuantiFERON-TB Gold blood analysis D. Mantoux test

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.

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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 client who is receiving continuous enteral feedings and reports diarrhea. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

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Correct Answer is D

Explanation

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