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 A
Explanation
A.
A. It's important to include the complete name of the medication to ensure clarity and accuracy in documentation.
B. Omitting the leading zero before a decimal point can lead to medication errors, so it's important to include it.
C. "U" is commonly used to denote units when documenting insulin dosage, so this statement is accurate.
D. "QOD" is an outdated abbreviation and can lead to confusion, so it should not be used; instead, "every other day" should be written out for clarity.
Correct Answer is C
Explanation
A. Encouraging the client to gain 2.3 kg (5 lb) per week may be excessive and unrealistic, potentially contributing to feelings of failure and exacerbating the client's condition.
B. Weighing the client once per week throughout hospitalization is important for monitoring weight changes, but it does not specifically address the immediate post-meal monitoring needed to prevent complications such as purging.
C. Monitoring the client for 1 hr after meals helps prevent behaviors such as purging or other forms of compensatory behaviors that may occur immediately after eating.
D. Allowing the client to choose meal times may not be appropriate as it can perpetuate disordered eating patterns. Establishing regular meal times is important for promoting consistent eating habits.
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