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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

Answer and Explanation

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

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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

Correct Answer is ["A","B","D"]

Explanation

A. Prolonged standing or sitting can worsen venous insufficiency and increase the risk of blood pooling in the legs. Encouraging the client to move around and avoid prolonged periods of immobility can help improve circulation.

B. Compression stockings help improve blood flow by applying pressure to the legs, reducing swelling and preventing blood from pooling. The client should be instructed to continue wearing them as prescribed by their healthcare provider.

C.Crossing the legs can impede blood flow and should be avoided altogether.

D. Sitting for extended periods can also contribute to blood pooling. Using a recliner allows the client to elevate their legs, promoting better circulation and reducing the risk of complications. The nurse should recommend using a recliner when sitting for long periods of time.

E.Elevating legs during sleep is generally advised to reduce venous pressure.

A. New screening protocols were developed, validated, and implemented. B. Clients who incurred disease complications promptly received rehabilitation. C. Average client scores improved on specific risk factor knowledge tests. D. More than half of at-risk clients were diagnosed early in their disease process.

Correct Answer is C

Explanation

A) Incorrect - Developing and implementing new screening protocols does not directly indicate the effectiveness of a primary prevention program. It might indicate improved detection, but not necessarily prevention.
B) Incorrect - This outcome relates to secondary prevention (rehabilitation after disease complications) rather than primary prevention.
C) Correct- An improvement in average client scores on risk factor knowledge tests suggests that the primary prevention program has successfully educated clients about behaviors and practices that can help prevent sexually transmitted diseases. This improvement indicates that clients have a better understanding of the risks and protective measures, which is a key indicator of program effectiveness.
D) Incorrect - Diagnosing clients early in their disease process is an outcome of early detection (secondary prevention), not primary prevention.

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Naxlex Comprehensive Predictor Exams

The home care nurse provided self-care instructions for a client with chronic venous insufficiency caused by deep vein thrombosis. Which instruction(s) should the nurse include in the client's discharge teaching plan? (Select all that apply.)

Correct Answer is ["A","B","D"]

Explanation

The nurse implements a primary prevention program for sexually transmitted diseases in a nurse-managed health center. Which outcome Indicates that the program was effective?

Correct Answer is C

Explanation

A client with a chlamydia infection receives a prescription for a single dose azithromycin 1 gram by mouth. The bottle is labeled "Azithromycin for Oral Suspension, USP 200 mg per 5 mL." How many mL should the nurse administer? (Enter numerical value only.)

The nurse implements a primary prevention program for sexually transmitted diseases in a nurse-managed health center. Which outcome Indicates that the program was effective?

An older client is being admitted to a short-term rehabilitation facility after a long hospitalization. The nurse is performing a functional assessment with the client. Which action should the nurse implement?

A college student brings a dorm roommate to the campus clinic because the roommate has been talking to someone who is not present. The client tells the nurse that the voices are saying, "Kill, kill." Which question should the nurse ask the client next?

An older client comes to the clinic with a family member. When the nurse attempts to take the client's health history, the client does not respond to questions in a clear manner. Which action should the nurse implement first?