Which of the following symptoms should a nurse expect to find when assessing an infant who is dehydrated in an emergency department? Select all that apply

Tachycardia.

Bloating.

Hypertension.

Irritability.

Answer and Explanation

Correct Answer : A,D

The correct answer is Choice A, Choice D.

Choice A rationale: Tachycardia, or an increased heart rate, is a common symptom of dehydration in infants. The body attempts to maintain adequate blood circulation despite reduced fluid volume by increasing the heart rate, which is a compensatory mechanism.

Choice B rationale: Bloating is not typically associated with dehydration in infants. Dehydration usually results in symptoms like dry mucous membranes and decreased skin turgor, rather than gastrointestinal symptoms like bloating.

Choice C rationale: Hypertension, or high blood pressure, is uncommon in dehydrated infants. Dehydration generally leads to hypotension (low blood pressure) due to decreased fluid volume in the circulatory system, which can result in reduced blood pressure.

Choice D rationale: Irritability is a frequent symptom of dehydration in infants. Reduced fluid intake and electrolyte imbalances can cause discomfort and distress, leading to irritability and increased fussiness in dehydrated infants.

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Correct Answer is A

Explanation

The correct answer is choice A. Auscultate the client's abdomen for bowel sounds. This is the first action the nurse should take because it provides information about the client's bowel motility and function. Opioid medications can decrease bowel motility and cause constipation. The nurse should assess the client's abdomen before implementing any interventions.

Choice B is not correct because providing privacy and a set time to defecate is a nonpharmacological intervention that can help prevent constipation, but it is not the first action the nurse should take.
Choice C is not correct because administering a fiber-based laxative is a pharmacological intervention that can help treat constipation, but it is not the first action the nurse should take. The nurse should also consider the client's fluid intake and preference before giving a laxative.
Choice D is not correct because encouraging the client to increase oral intake of fluids is a nonpharmacological intervention that can help prevent constipation, but it is not the first action the nurse should take. The nurse should also consider the client's fluid balance and medical condition before giving fluids.

A. Obtain blood pressure readings using the client's right arm. B. Limit range-of-motion exercises with the affected arm. C. Keep both arms below the level of the client's heart. D. Use the client's left arm to obtain blood samples.

Correct Answer is D

Explanation

The client had a right radical mastectomy, which can lead to lymphedema, a buildup of fluid that can cause swelling in the arm. Using the client's left arm to obtain blood samples can help prevent injury to the affected arm and reduce the risk of lymphedema. Obtaining blood pressure readings with the client's left arm is also recommended. Range-of-motion exercises are important to prevent stiffness, and elevating the affected arm can help reduce swelling.

A: Obtaining blood pressure readings with the client's right arm can cause injury and increase the risk of lymphedema.

B: Limiting range-of-motion exercises can lead to stiffness and may not prevent lymphedema.

C: Keeping both arms below the level of the client's heart can help reduce swelling, but does not directly prevent lymphedema.

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Which of the following symptoms should a nurse expect to find when assessing an infant who is dehydrated in an emergency department? Select all that apply

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting in the plan of care for a client who has constipation after receiving opioid medication for incisional pain. Which of the following actions should the nurse take first?

Correct Answer is A

Explanation

A nurse is caring for a client who is postoperative following a right radical mastectomy. Which of the following actions should the nurse take to prevent the development of lymphedema?

Correct Answer is D

Explanation

Which of the following symptoms should a nurse expect to find when assessing an infant who is dehydrated in an emergency department? Select all that apply

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