When assessing an infant with moderate dehydration, a nurse would expect which assessment findings?
Fever and hypertension.
Increased specific gravity.
Tachypnea and tachycardia.
Bulging posterior fontanel.
The Correct Answer is C
Choice A rationale:
Fever and hypertension are not typical findings in moderate dehydration. Dehydration often leads to hypotension rather than hypertension, and fever is not a direct consequence of dehydration.
Choice B rationale:
Increased specific gravity can be a sign of dehydration, but it is not as specific or sensitive as tachypnea (rapid breathing) and tachycardia (elevated heart rate), which occur due to the body's compensatory mechanisms in response to dehydration.
Choice C rationale:
Tachypnea and tachycardia are key indicators of moderate dehydration in infants. The body tries to maintain perfusion by increasing the heart rate and respiratory rate. These signs are more reliable indicators of dehydration than specific gravity or fever.
Choice D rationale:
Bulging posterior fontanel is not a typical finding in dehydration. A sunken fontanel might be more indicative of dehydration, as fluid shifts from the intracellular to the extracellular space.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Absence of bowel sounds is not a priority in this situation as it is common for bowel sounds to be absent temporarily after surgery due to anesthesia and decreased peristalsis. It should be monitored, but it doesn't require immediate nursing action.
Choice B rationale:
A pulse rate of 150 per minute is a significant finding in a 10-year-old patient after surgery. Tachycardia can indicate pain, anxiety, hypovolemia, or other postoperative complications. Immediate nursing action is required to assess the cause and initiate appropriate interventions.
Choice C rationale:
Blood-tinged urine from the ureteral catheter might be expected after a surgical procedure involving the urinary system. While it requires monitoring, it is less urgent than addressing a high pulse rate in a postoperative child.
Choice D rationale:
Serosanguineous drainage on the incisional dressing is a normal finding in the immediate postoperative period. It indicates minor oozing of blood mixed with serous fluid. While it requires monitoring, it is not as concerning as the elevated pulse rate.
Correct Answer is A
Explanation
An hour before meals and at bedtime.
Choice A rationale:
Scheduling chest physiotherapy an hour before meals and at bedtime is optimal. This timing helps prevent aspiration during meals and aids in clearing secretions before sleep. It complements the patient's meal schedule and sleep routine.
Choice B rationale:
Every six hours around the clock could disrupt the patient's sleep and meal times. Chest physiotherapy might not align well with the patient's daily activities, potentially affecting treatment compliance and effectiveness.
Choice C rationale:
Performing chest physiotherapy upon awakening and after meals might increase the risk of aspiration during meals. Clearing airways before meals is safer, and performing it right after meals could cause discomfort.
Choice D rationale:
Evenly spaced physiotherapy when awake lacks synchronization with meal and sleep times. This approach might not optimize treatment effects and patient convenience.
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