Patient Data
History and Physical Nurses' Notes Laboratory Results Flow Sheet
Review H and P, nurse's note, laboratory result, and flow sheet.
What information should the nurse collect as part of the focused assessment for dehydration in this child? Select all that apply.
Level of consciousness
Capillary refill
Temperature
Blood pressure
Pupil size and reactiveness
Skin turgor
Heart rate
Correct Answer : B,C,D,E,H
- Capillary refill: This is a quick and simple way to assess the adequacy of peripheral perfusion and can help identify signs of dehydration.
- Skin turgor: Assessing the skin turgor, or the elasticity of the skin, is another useful indicator of dehydration.
- Heart rate: Tachycardia can be a sign of dehydration, so monitoring the heart rate is an important component of the assessment.
- Blood pressure: Blood pressure can be affected by dehydration, so monitoring it is important in determining the severity of dehydration and in guiding appropriate interventions.
- Temperature: Fever is a potential cause of dehydration, so monitoring the temperature is an important part of the assessment.
- Skin color of hands and feet: Checking the color of the skin on the hands and feet can help identify signs of poor perfusion and dehydration.
Assessing the level of consciousness, pupil size and reactiveness, and respiratory rate are important aspects of the neurological and respiratory assessments but are not specific to the assessment of dehydration.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
NPO status is crucial before a surgical procedure, especially when anesthesia will be administered. It helps prevent complications related to aspiration of gastric contents during the procedure. Failure to adhere to the NPO status can lead to serious respiratory problems, such as aspiration pneumonia.
It is important for the nurse to confirm the NPO status with the client to ensure that they have followed the appropriate fasting guidelines. This should be done to ensure the client's safety during the surgery.
While determining when the client last had pain medication, offering assistance to the restroom, and reviewing postoperative instructions are important aspects of preoperative care, confirming NPO status is the most critical nursing action in this particular scenario.
Correct Answer is ["25"]
Explanation
The prescription is for 1 gram of azithromycin, which is 1000 mg. The concentration of
the suspension is 200 mg per 5 mL. To calculate the amount in mL:
1000 mg / 200 mg per 5 mL = 25 mL
The nurse should administer 25 mL of the suspension.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.