Nokea
Specify 2 parameters the nurse should monitor to assess the client's progress.
- A. Number of steatorrhea stools
- B. Intake and output
- C. Respiratory Status (Monitor respiratory)
- D. Presence of periorbital edema
Correct Answer: B,C
Rationale: The correct parameters for the nurse to monitor to assess the client's progress are intake and output (B) and respiratory status (C). Monitoring intake and output is crucial to assess fluid balance and kidney function. Changes in these values can indicate dehydration or fluid overload. Respiratory status should be monitored to assess oxygenation and ventilation, which are essential for tissue perfusion and overall health.
The incorrect choices are A, D, E, F, and G. A (Number of steatorrhea stools) is not directly related to assessing overall client progress. D (Presence of periorbital edema) may be indicative of fluid retention but is not as direct as intake and output monitoring. Choices E, F, and G are not provided, thus not applicable to the question.
You may also like to solve these questions
The nurse should teach the parents to take which of the following actions during a seizure?
- A. Minimize movement of the limbs.
- B. Clear the area of hard objects.
- C. Place the child in a prone position.
- D. Insert a tongue blade between the teeth.
Correct Answer: B
Rationale: The correct answer is B: Clear the area of hard objects. This action is crucial during a seizure to prevent injury. Hard objects can cause harm if the child hits them during convulsions. Minimizing limb movement is not recommended as it may lead to further injury. Placing the child in a prone position can obstruct breathing and should be avoided. Inserting a tongue blade can also cause harm and is not recommended. Clearing the area of hard objects is the most effective way to ensure safety during a seizure.
Which of the following statements should the nurse make?
- A. You need to come back in a week for retesting.
- B. I have to notify the public health department.
- C. I have to contact your parents.
- D. Let's review the side effects of metronidazole.
Correct Answer: B
Rationale: The correct answer is B: I have to notify the public health department. This statement is crucial in cases of reportable diseases to prevent the spread of infection. Notifying the public health department is a legal and ethical responsibility to ensure appropriate measures are taken. Choice A is incorrect because it lacks urgency in notifying the proper authorities. Choice C is incorrect as contacting the patient's parents may not be necessary in this situation. Choice D is incorrect as reviewing side effects of metronidazole is not the priority when dealing with a reportable disease.
Which of the following actions should the nurse take to encourage acceptance of the medication?
- A. Provide an ice pop after administering the medication.
- B. Give 4 oz of milk with the medication.
- C. Mix the medication with the child's favorite food.
- D. Dilute the medication with 8 oz of water.
Correct Answer: A
Rationale: The correct answer is A. Providing an ice pop after administering the medication can create a positive association with taking the medication. The cold sensation and flavor can help mask any unpleasant taste, making the child more likely to accept the medication. Choice B might not be effective as milk may interfere with the medication's absorption. Choice C could work if the child does not detect the medication in the food. Choice D is not ideal as diluting the medication may reduce its effectiveness.
Which of the following findings should the nurse identify as a manifestation of severe dehydration?
- A. Capillary refill time 3 seconds
- B. Sunken anterior fontanel
- C. Weight loss of 5%
- D. Produces tears when crying
Correct Answer: B
Rationale: The correct answer is B: Sunken anterior fontanel. This finding is indicative of severe dehydration in infants, as it suggests significant fluid loss and decreased tissue turgor. A sunken fontanel is a late sign of dehydration. Choice A is incorrect as a capillary refill time of 3 seconds is within normal limits. Choice C may be seen in mild to moderate dehydration, but severe dehydration would involve a greater weight loss. Choice D is not specific to dehydration, as tear production can still occur even in cases of dehydration.
Which of the following laboratory findings should the nurse expect?
- A. Decreased prothrombin time
- B. Increased Hgb level
- C. Increased RBC
- D. Decreased platelet count
Correct Answer: D
Rationale: The correct answer is D: Decreased platelet count. This is expected in a patient with thrombocytopenia, which is a condition characterized by low platelet levels. Thrombocytopenia can lead to abnormal bleeding and bruising due to impaired blood clotting.
A: Decreased prothrombin time would not be expected in thrombocytopenia, as it measures the clotting ability of the plasma, not platelets.
B: Increased Hgb level and C: Increased RBC levels are not typically associated with thrombocytopenia.
In summary, a decreased platelet count is the most relevant laboratory finding to expect in a patient with thrombocytopenia.