A nurse is caring for an infant who is dehydrated and requires IV therapy. The nurse should monitor the infant's response to therapy by performing which of the following actions?
Taking the infant's vital signs every 2 hr
Counting the number of wet diapers every shift
Weighing the infant at the same time every day
Measuring the infant's head circumference twice per day
The Correct Answer is C
A. Taking the infant's vital signs every 2 hr: Monitoring vital signs every 2 hours can help assess the infant’s general condition and detect changes in heart rate and blood pressure, which can indicate changes in hydration status. However, it might not be sufficient alone to monitor fluid status.
B. Counting the number of wet diapers every shift: Tracking the number of wet diapers is an effective way to monitor the infant's fluid output and hydration status. An increase in wet diapers typically indicates improved hydration. This is a practical and non-invasive method for assessing the effectiveness of IV therapy in infants.
C. Weighing the infant at the same time every day: Daily weights are a critical measure of fluid balance in infants. A consistent daily weight check provides a direct and accurate assessment of the infant’s hydration status and response to IV therapy.
D. Measuring the infant's head circumference twice per day: Measuring head circumference is not relevant for monitoring hydration status. It is typically used to assess growth and development in infants, not fluid balance or response to IV therapy.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Supine: Lying on the back can limit lung expansion and is not the best position for a child with respiratory issues. It can contribute to atelectasis and does not facilitate effective breathing.
B. Prone: The prone position can improve oxygenation and ventilation, particularly in severe respiratory distress, but it may not be the most comfortable or practical for all patients, especially in a non-ICU setting.
C. Upright: Sitting upright or in a high Fowler's position is optimal for lung expansion. It facilitates easier breathing and helps the lungs expand more fully, allowing for better oxygenation.
D. Side-lying: Side-lying may be comfortable but does not provide as much benefit for lung expansion as the upright position. It is less effective in promoting maximal lung expansion compared to the upright position.
Correct Answer is C
Explanation
Inject insulin in the deltoid muscle: Insulin is administered subcutaneously, not intramuscularly. Common sites for insulin injection include the abdomen, thighs, and upper arms.
B. Take glyburide with breakfast: Glyburide is an oral hypoglycemic agent used for type 2 diabetes, not type 1 diabetes. Adolescents with type 1 diabetes require insulin.
C. Obtain an influenza vaccine annually: People with diabetes are at higher risk for complications from influenza, so annual vaccination is recommended to prevent illness.
D. Administer glucagon for hyperglycemia: Glucagon is used to treat severe hypoglycaemia, not hyperglycaemia. For hyperglycemia, insulin administration and monitoring blood glucose levels are key.
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