This is an 11-month-old male with a 2-day history of fussiness, increased nasal secretions, and cough. The baby is 24.3 lb. (11 kg). He was born at 34 weeks gestation and spent several weeks in the neonatal intensive care unit for poor feeding.
He is currently up to date on vaccinations and is meeting appropriate developmental milestones. The parents deny that he takes any medications at home.
Review H and P and flow sheet.
Select which assessment findings indicate that the baby has an increased fluid requirement. Select all that apply.
Temperature 103 °F (39.4 °C)
Blood pressure 89/51 mmHg
Respiratory rate 55 breaths/min
Copious, clear secretions from both nostrils
Oxygen saturation 95%
Wet diaper with 12 mL of urine
Heart rate 159 bpm
Correct Answer : A,C,D,E
Fever increases fluid loss through perspiration.
Increased respiratory rate can lead to increased fluid loss through evaporation. Increased nasal secretions can result in fluid loss.
High oxygen flow can cause drying of the mucous membranes and increase fluid requirements.
The following findings do not necessarily indicate increased fluid requirements: Blood pressure alone does not indicate increased fluid requirements.
Oxygen saturation within the normal range does not indicate increased fluid requirements.
Although urine output is important to assess hydration status, 12 mL of urine may not necessarily indicate increased fluid requirements.
Heart rate alone does not indicate increased fluid requirements.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct answer ischoice A.
Choice A rationale:
Having the client vocalize the instructions provided ensures that they have understood the information correctly.This method allows the nurse to confirm comprehension and clarify any misunderstandings.
Choice B rationale:
Providing written instructions for eye drop administration is helpful but does not ensure that the client understands the instructions.It is a good supplementary measure but should not be the sole method of communication.
Choice C rationale:
Speaking clearly and facing the client for lip reading is important, especially for clients with hearing impairments.However, it does not guarantee that the client has understood the instructions.
Choice D rationale:
Ensuring that someone will stay with the client for 24 hours is a good safety measure but does not directly address the client’s understanding of the discharge instructions.
Correct Answer is A
Explanation
Tracheostomy care is done to keep the trach tube clean and prevent infections.It involves suctioning and cleaning parts of the tube and the skin around the stoma. A code blue is a hospital emergency code that indicates a life-threatening situation, such as cardiac or respiratory arrest.It requires immediate attention from trained personnel.
- Call for an assistant to stay with the client who is receiving tracheostomy care and continue the procedure.
- Respond to the code blue and assist with resuscitation efforts for the other client.
- Return to the client who is receiving tracheostomy care as soon as possible and complete the procedure.
Therefore, the correct answer isa. Call for an assistant.
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