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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.

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Correct Answer is A

Explanation

Wearing protective goggles is important during suctioning to protect the nurse's eyes from potential splashes or aerosolized secretions. Suctioning can generate forceful coughing, gagging, or sneezing in the client, which may cause secretions or mucus to be expelled forcefully and potentially come into contact with the nurse's eyes. Wearing goggles helps prevent eye exposure and reduces the risk of infection transmission.

Applying a water-soluble lubricant to the catheter may be necessary to facilitate the insertion of the suction catheter into the tracheostomy tube, but it is not the most crucial action to include when performing suctioning.

Instilling normal saline before suctioning is not recommended as it can cause potential harm to the client's airway. Instilling saline can lead to bronchospasm, mucosal damage, and other complications. Suctioning should only be performed when necessary to remove secretions and maintain a patent airway.

Instructing the client to cough as the suction tip is removed is not necessary or recommended. Coughing during the suctioning process can be uncontrolled and may increase the risk of trauma to the airway. The nurse should instead provide supportive care and reassurance to the client throughout the procedure.

A. Determine when the client last had pain medication. B. Offer to assist the client to the restroom to void. C. Review postoperative instructions with the client. D. Confirm that the client has been NPO since midnight.

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.

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Naxlex Comprehensive Predictor Exams

When performing suctioning for a client with a tracheostomy, which action should the nurse include?

Correct Answer is A

Explanation

The nurse is assigned to provide care for a client who is scheduled for a laparoscopic cholecystectomy in two hours, at 0900. What nursing action is most important?

Correct Answer is D

Explanation

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