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. Assist with administering a blood transfusion. Blood transfusions are often necessary in sickle cell crisis to manage severe anemia and improve oxygen delivery to tissues. This action helps alleviate the symptoms of the crisis and prevent complications.
B. Withhold opioids to avoid dependence. Opioids are essential for managing the severe pain associated with sickle cell crises. Concerns about dependence should not prevent adequate pain management in an acute setting.
C. Encourage exercise. During a sickle cell crisis, rest is crucial to reduce oxygen demand and prevent further sickling of red blood cells. Exercise is contraindicated during a crisis.
D. Initiate a 2 L/day fluid restriction. Adequate hydration is critical in managing sickle cell crisis, as it helps prevent further sickling of cells. Fluid restriction is inappropriate and could worsen the condition.
Correct Answer is B
Explanation
A. Maintain medical asepsis during dressing changes: While cleanliness is important, aseptic (sterile) technique is typically required for burn care to prevent infection.
B. Administer pain medication 30 min to 1 hour before physical therapy: Pain management is crucial to facilitate participation in physical therapy and improve outcomes.
C. Allow the child to set her own schedule for care: A structured schedule is necessary to ensure regular treatment and care for burns.
D. Provide low-calorie snacks: High-calorie, protein-rich foods are necessary to meet increased metabolic demands for healing.
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