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NurseDive Free Nursing Practice Question
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.
A. Temperature 103 °F (39.4 °C)
Fever increases fluid loss through perspiration.
B. Blood pressure 89/51 mmHg
Blood pressure alone does not indicate increased fluid requirements.
C. Respiratory rate 55 breaths/min
Increased respiratory rate can lead to increased fluid loss through evaporation.
D. Copious, clear secretions from both nostrils
Increased nasal secretions can result in fluid loss.
F. Oxygen saturation 95%
High oxygen flow can cause drying of the mucous membranes and increase fluid requirements.
G. Wet diaper with 12 mL of urine
Although urine output is important to assess hydration status, 12 mL of urine may not necessarily indicate increased fluid requirements.
H. Heart rate 159 bpm
Heart rate alone does not indicate increased fluid requirements.
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Full Explanation
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.
Similar Questions
After receiving a change of shift report for clients on a medical surgical unit, which activity should the nurse delegate to the practical nurse (PN)?
A. Evaluate and update plans of care for clients.
Evaluating and updating plans of care for clients is a responsibility that falls within the scope of practice of registered nurses. It requires a higher level of assessment, clinical judgment, and decision-making, which are typically beyond the scope of practice of a practical nurse.
B. Verify the readiness of clients for discharge.
Verifying the readiness of clients for discharge typically involves comprehensive assessments, coordination with other healthcare professionals, and decision-making regarding the appropriateness of discharge. This task is generally performed by registered nurses (RNs) or other members of the healthcare team with advanced training.
C. Insert urinary catheters for uncomplicated clients.
Delegation involves assigning tasks to individuals who have the appropriate skills and competence to perform them safely and effectively. Inserting urinary catheters for uncomplicated clients is a task that can be delegated to a practical nurse. It is a common procedure within the scope of practice for a practical nurse, and it does not require the level of assessment and critical thinking involved in evaluating and updating plans of care or receiving a postoperative client and conducting an assessment.
D. Receive a postoperative client and conduct the assessment.
Receiving a postoperative client and conducting the assessment involves comprehensive assessment skills and critical thinking, which are typically within the scope of practice of a registered nurse or an advanced practice nurse.
Full Explanation
Delegation involves assigning tasks to individuals who have the appropriate skills and competence to perform them safely and effectively. Inserting urinary catheters for uncomplicated clients is a task that can be delegated to a practical nurse. It is a common procedure within the scope of practice for a practical nurse, and it does not require the level of assessment and critical thinking involved in evaluating and updating plans of care or receiving a postoperative client and conducting an assessment.
Verifying the readiness of clients for discharge typically involves comprehensive assessments, coordination with other healthcare professionals, and decision-making regarding the appropriateness of discharge. This task is generally performed by registered nurses (RNs) or other members of the healthcare team with advanced training.
Evaluating and updating plans of care for clients is a responsibility that falls within the scope of practice of registered nurses. It requires a higher level of assessment, clinical judgment, and decision-making, which are typically beyond the scope of practice of a practical nurse.
Receiving a postoperative client and conducting the assessment involves comprehensive assessment skills and critical thinking, which are typically within the scope of practice of a registered nurse or an advanced practice nurse.
The nurse discovers that a male client has attempted suicide by slashing his wrists. Which action(s) should the nurse do first?
A. Check the client's level of consciousness.
Assessing the client's level of consciousness involves observing their responsiveness, orientation, and ability to follow commands. If the client is unresponsive or exhibits any signs of altered consciousness, the nurse should immediately activate the emergency response system and begin resuscitative measures, such as administering oxygen and initiating cardiopulmonary resuscitation (CPR) if necessary. Once the client's level of consciousness is established and the emergency response system has been activated if necessary, the nurse can proceed to assess the depth of the slashes, estimate the amount of blood loss, and find the object used to cause the injuries. These assessments will provide important information about the extent and severity of the client's injuries, which will guide subsequent interventions.
B. Determine the depth of the slashes.
C. Estimate the amount of blood loss.
D. Find the object used to cause the injuries.
Full Explanation
Assessing the client's level of consciousness involves observing their responsiveness, orientation, and ability to follow commands. If the client is unresponsive or exhibits any signs of altered consciousness, the nurse should immediately activate the emergency response system and begin resuscitative measures, such as administering oxygen and initiating cardiopulmonary resuscitation (CPR) if necessary.
Once the client's level of consciousness is established and the emergency response system has been activated if necessary, the nurse can proceed to assess the depth of the slashes, estimate the amount of blood loss, and find the object used to cause the injuries. These assessments will provide important information about the extent and severity of the client's injuries, which will guide subsequent interventions.
Patient Data
History and Physical Nurses' Notes Laboratory Results Flow Sheet
Review H and P, nurse's note, laboratory result, and flow sheet.
What information should the nurse collect as part of the focused assessment for dehydration in this child? Select all that apply.
A. Level of consciousness
Assessing the level of consciousness, pupil size and reactiveness, and respiratory rate are important aspects of the neurological and respiratory assessments but are not specific to the assessment of dehydration
B. Capillary refill
This is a quick and simple way to assess the adequacy of peripheral perfusion and can help identify signs of dehydration.
C. Temperature
Fever is a potential cause of dehydration, so monitoring the temperature is an important part of the assessment.
D. Blood pressure
Blood pressure can be affected by dehydration, so monitoring it is important in determining the severity of dehydration and in guiding appropriate interventions.
F. Pupil size and reactiveness
Assessing the level of consciousness, pupil size and reactiveness, and respiratory rate are important aspects of the neurological and respiratory assessments but are not specific to the assessment of dehydration
G. Skin turgor
Assessing the skin turgor, or the elasticity of the skin, is another useful indicator of dehydration.
H. Heart rate
Tachycardia can be a sign of dehydration, so monitoring the heart rate is an important component of the assessment.
Full Explanation
- Capillary refill: This is a quick and simple way to assess the adequacy of peripheral perfusion and can help identify signs of dehydration.
- Skin turgor: Assessing the skin turgor, or the elasticity of the skin, is another useful indicator of dehydration.
- Heart rate: Tachycardia can be a sign of dehydration, so monitoring the heart rate is an important component of the assessment.
- Blood pressure: Blood pressure can be affected by dehydration, so monitoring it is important in determining the severity of dehydration and in guiding appropriate interventions.
- Temperature: Fever is a potential cause of dehydration, so monitoring the temperature is an important part of the assessment.
- Skin color of hands and feet: Checking the color of the skin on the hands and feet can help identify signs of poor perfusion and dehydration.
Assessing the level of consciousness, pupil size and reactiveness, and respiratory rate are important aspects of the neurological and respiratory assessments but are not specific to the assessment of dehydration.