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 A
Explanation
A. Lime ice pop: A lime ice pop is a good option because it is cold, soothing, and less likely to irritate the throat or cause bleeding. The cold temperature can help reduce swelling and provide comfort. Additionally, it is not acidic or dairy-based, which makes it a safe choice.
B. Cranberry juice: Cranberry juice is acidic, which can irritate the throat and increase discomfort after a tonsillectomy. Acidic foods and drinks should be avoided during the recovery period to prevent irritation and pain.
C. Ice cream: While ice cream is cold and soothing, it contains dairy, which can increase mucus production. This may lead to discomfort and make swallowing more difficult post-surgery. It’s best to avoid dairy products immediately following a tonsillectomy.
D. Hot tea : Hot beverages should be avoided because they can cause vasodilation and increase the risk of postoperative bleeding. Cold or room temperature liquids are preferred to minimize discomfort and prevent complications.
Correct Answer is C
Explanation
A. Attempt to obtain a throat culture: This is contraindicated because manipulating the throat could exacerbate airway obstruction, leading to a potential respiratory emergency.
B. Use a tongue depressor to observe the back of the throat: This can provoke a spasm or cause complete airway obstruction in a child with epiglottitis and should be avoided.
C. Apply humidified oxygen via a mask: This helps to keep the airways moist and can provide some relief and improve oxygenation while minimizing the risk of airway manipulation.
D. Initiate airborne precautions: Epiglottitis primarily requires droplet precautions, not airborne. Airborne precautions are used for diseases like tuberculosis, which are spread through smaller droplets that remain suspended in the air.
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