NCLEX 10000 Management of Care
A nurse is teaching a new mother about exercise and injury prevention. Which statement by the client requires further teaching?
"I'm allowed to jog in place." Explanation: The client requires additional teaching if she states that she may jog in place. Jogging can increase the amount of lochia rubra, which indicates new bleeding. Muscle flexing and stretching, Kegel exercises, and pelvic tilts are safe to do during the first 3 weeks postpartum. Stretching and flexing muscles relieves tension. Kegel exercises tone the muscles of the pelvic floor. Pelvic tilts strengthen the muscles of the lower back.
Which statement by a staff nurse on the orthopedic floor indicates the need for further staff education?
"The client is receiving physical therapy twice per day, so he doesn't need a continuous passive motion device." Explanation: Further staff education is needed when the nurse states that the continuous passive motion device isn't needed because the client receives physical therapy twice per day. The continuous passive motion device should be used in conjunction with physical therapy because the device helps prevent adhesions.
A physician orders blood glucose levels every 4 hours for a 4-year-old child with brittle type 1 diabetes. The parents are worried that drawing so much blood will traumatize their child. How can the nurse best reassure the parents? a) "Your child is young and will soon forget this experience." b) "Our laboratory technicians use tiny needles and they're really good with children." c) "I'll see if the physician can reduce the number of blood draws." d) "Your child will need less blood work as his glucose levels stabilize."
"Your child will need less blood work as his glucose levels stabilize." Correct Explanation: Telling the parents that the number of blood draws will decrease as their child's glucose levels stabilize engages them in the learning process and gives them hope that the present discomfort will end as the child's condition improves.
The nurse has been assigned to provide care for four clients at the beginning of the day shift. In what order should the nurse assess these clients? All options must be used.
*a client with peptic ulcer disease experiencing a sudden onset of acute stomach pain *a client who is requesting pain medication 2 days after surgery to repair a fractured jaw *a client with suspected gastric cancer who is on nothing-by-mouth (NPO) status for tests *a client awaiting surgery for a hiatal hernia repair at 1100 Explanation: The client with peptic ulcer disease who is experiencing a sudden onset of acute stomach pain should be assessed first by the nurse. The sudden onset of stomach pain could be indicative of a perforated ulcer, which would require immediate medical attention. It is also important for the nurse to thoroughly assess the nature of the client's pain. The client with the fractured jaw is experiencing pain and should be assessed next. The nurse should then assess the client who is NPO for tests to ensure NPO status and comfort. Last, the nurse can assess the client before surgery.
A client is being admitted with a nursing home-acquired pneumonia. The unit has four empty beds in semiprivate rooms. The room that would be most suitable for this client is the one with a:
60-year-old client admmitted for investigation of transient ischemic atttacks. Explanation: The client with a possible transient ischemic attack is the only client who has not had surgery and is not immunocompromised. The client with a recent surgery and incision should not be exposed to a client with infection.
The nurse applies which ethical principle when telling the truth to a client about the prognosis?
Veracity The ethical principle of veracity is the obligation to tell the truth and not to lie or deceive others.
During morning assessment, a nurse assesses four clients. Which client is the priority for follow up?
A 73-year-old client who has pneumonia with coarse crackles, is receiving 2 L/minute of oxygen, and has an I.V. line. Explanation: The 73-year-old client with pneumonia should be the nurse's priority because of the oxygenation complications and the audible crackles that may result from fluid overload from the I.V. line.
An employee health nurse is assisting a stressed working mother with value clarification. Which of the following best defines value clarification?
A process by which people come to understand their own values and value systems. Explanation: Value clarification is a process by which people come to understand their own values and value systems. A value is a belief about the worth of something, about what matters, that acts as a standard to guide one's behavior. A value system is an organization of values in which each is ranked along a continuum of importance, often leading to a personal code of conduct
A nurse is evaluating a stage II pressure ulcer on a client. Which wound assessment findings should prompt the nurse to request a referral from the wound care nurse? a) A wound measuring 1 cm × 2 cm × 0.5 cm with a red, moist wound bed b) A wound measuring 2 cm × 2 cm × 0.5 cm with granulation tissue c) A wound measuring 9 cm × 5 cm × 0.5 cm with granulation tissue d) A wound measuring 2 cm × 2 cm × 0.5 cm with tan leathery appearance
A wound measuring 2 cm × 2 cm × 0.5 cm with tan leathery appearance Correct Explanation: A wound (regardless of its size) that contains tan, leathery tissue requires evaluation by the wound care nurse. This wound most likely requires debridement before wound healing can take place. Although option 1 describes a large wound, it's showing signs of healing, so a consult isn't necessary. Option 2 describes a stage II wound that has a clean wound bed; a wound nurse consult isn't necessary for this type of wound. The wound described in option 4 is small and shows signs of healing; a wound care consult isn't required at this time
A nurse is working within the managed care delivery model. Which of the following is true regarding managed care?
All systems reflect the values of efficiency and effectiveness. Explanation: All systems in the managed care delivery model reflect the values of efficiency and effectiveness. Different plans may have different values underlying the delivery of care. However, they all reflect the business plan values of efficiency and effectiveness.
A mother reports she cannot afford the antibiotic azithromycin, which was prescribed by the physician for her toddler's otitis media. The nurse's best response is to:
Confer with the physician about whether a less expensive drug could be ordered. The nurse must act as an advocate for the client when the client cannot afford treatment. It is possible to substitute a less expensive antibiotic. Correct procedure includes contacting the physician to explain the mother's economic situation and request a substitution. For example, amoxicillin is more economical than azithromycin
When developing the teaching plan for a client who uses a walker, which principle should a nurse consider?
When maximum support is required, the walker should be moved ahead approximately 6″ (15 cm) while both legs support the client's weight. Explanation: To prevent falls, a client who needs maximum support should move the walker ahead approximately 6″. The client's legs should bear the weight of his body. The hand bar of the walker should be level with the client's waist, not below it. If one leg is weaker than the other, the walker and the weak leg move together while the stronger leg bears the client's weight.
The nurse is caring for an adolescent with cancer who is well informed about the medical condition and treatment. The adolescent refused the morning medications and states intentions of refusing all future medications. What is the best action by the nurse?
Document the adolescent's choice and offer to discuss feelings about the medication. Explanation: The client has the right to choose whether to take the medication. The nurse should try to determine the reason for the adolescent not wanting the medication other than choice (e.g., side effects, fear of falling asleep and not waking).
A multiparous client at 16 weeks' gestation is diagnosed as having a fetus with probable anencephaly. The client is a devout Baptist and has decided to continue the pregnancy and donate the neonatal organs after the death of the neonate. Which action by the nurse would be most appropriate? a) Ask the client if she has discussed this with her family. b) Contact the client's minister to discuss the client's options related to the pregnancy. c) Explore his or her own feelings about the issues of anencephaly and organ donation. d) Advise the client that the prolonged neonatal death will be very painful for her.
Explore his or her own feelings about the issues of anencephaly and organ donation. Correct Explanation: Anencephaly is a neural tube defect that is not compatible with life, although some infants with anencephaly live for several days before death occurs. When the client has decided to continue the pregnancy and donate the neonatal organs after the death of the neonate, the nurse should remain nonjudgmental. The nurse should explore his or her feelings about the issue of anencephaly and organ donation. The nurse should not make judgments about the client's position, nor should the nurse try to persuade the client to terminate the pregnancy.
A nurse from a surgical unit is asked to work on the pediatric unit during a staffing shortage. The surgical nurse has not worked in pediatrics for 10 years and is not familiar with the unit. The surgical nurse approaches the nurse manager and claims not to be competent to work on the pediatric unit. What should the nurse manager do?
Find another nurse to cover the unit and send the nurse back to the surgery unit. Explanation: Nurses are accountable for their practice and must recognize the limitations of their own competency. To the extent possible, the nurse manager must ensure nurses working on their units have the required knowledge, skills, and competencies.
A client with an exacerbation of chronic obstructive pulmonary disease (COPD) is admitted to the hospital. Which nursing diagnosis requires the nurse to collaborate with other health team members to achieve the best outcome for the client?
Impaired gas exchange Explanation: Impaired gas exchange requires collaboration between the nurse, physician, and respiratory therapist to help achieve the best respiratory outcome for the client. Medications, oxygen, nebulizer treatments, and arterial blood gas analyses all require a physician's order. The respiratory therapist administers the oxygen and nebulizer treatments. The nurse assesses the client's response to medications and respiratory treatments and provides feedback to the physician and respiratory therapist.
A young adult client who has been diagnosed with type 1 diabetes has an insulin drip to aid in lowering the serum blood glucose level of 600 mg/dL (33.3 mmol/L). The client is also receiving ciprofloxacin IV. The health care provider (HCP) prescribes discontinuation of the insulin drip. What should the nurse do next? a) Discontinue the insulin drip, as prescribed. b) Hang the next IV dose of antibiotic before discontinuing the insulin drip. c) Inform the HCP that the client has not received any subcutaneous insulin yet. d) Add glargine to the insulin drip before discontinuing it.
Inform the HCP that the client has not received any subcutaneous insulin yet. Explanation: Because subcutaneous administration of insulin has a slower rate of absorption than IV insulin, there must be an adequate level of insulin in the bloodstream before discontinuing the insulin drip; otherwise, the glucose level will rise.
An elderly man experiences a thrombotic cerebrovascular accident and subsequent flaccid hemiplegia of the right side. When planning care for this client, rehabilitation begins:
When the client is admitted to the hospital. Explanation: Rehabilitation for a client who has sustained a cerebrovascular accident begins at the time he is admitted to the hospital. The first goal of rehabilitation should be to help prevent deformities.
A client who tested positive for human immunodeficiency virus (HIV) and has pancreatitis is admitted to the medical unit. The nurse director from another unit comes into the medical unit nurses' station and begins reading the client's chart. The staff nurse questions the director about reading the client's chart. The director states that the client is her neighbor's son. What action should the nurse take to protect the client's right to privacy? a) Ask the nurse director if she has permission to read the client's chart, and if she doesn't, tell her she needs to obtain it before further reading. b) Remind the nurse director not to share the client's medical information with anyone because of his HIV status. c) Report the incident to the medical director. d) Inform the nurse director she's violating the client's right to privacy and ask her to return the chart.
Inform the nurse director she's violating the client's right to privacy and ask her to return the chart. Correct Explanation: Personal health information may not be used for purposes not related to health care. The nurse director found reading the chart isn't providing health care to the client and, therefore, doesn't require access to the chart. The nurse should confront the nurse director and ask her to return the client's chart. The director shouldn't have access to this client's health care information regardless of his HIV status. If she doesn't comply with the nurse's request, the nurse should report the incident to her nurse manager, so the infraction can be reported through the proper channels.
Eight farm workers are admitted to the emergency department after they were splashed with "a couple of chemicals" at work 30 minutes ago. They have watery/itchy eyes, slight cough, diaphoresis, constricted pupils, and are conscious and oriented. Their clothes are wet. What action should the nurse do first?
Isolate the clients. Explanation: Safety of the staff and others is the first priority. Isolating reduces the chance of contaminating others (secondary contamination)
Which of the following involves charting information about the client and client care in chronological order? a) Focus charting. b) PIE charting. c) SOAP charting. d) Narrative charting.
Narrative charting. Correct Explanation: Narrative charting involves writing information about the client and client care in chronological order. In SOAP charting, everyone involved in the client's care makes entries in the same location in the chart. Focus charting follows a data, action, and response (DAR) model to reflect the steps in the nursing process. PIE charting is a method of recording the client's progress under the headings of problem, intervention, and evaluation.
A nurse is caring for a client with multiple sclerosis. The client informs the nurse that a lawyer is coming to prepare a living will and requests the nurse to sign as witness. Which of the following actions should the nurse take?
Note that the nurse caring for the client cannot be a witness. Explanation: A living will is an instructive form of an advance directive. It is a written document that identifies a person's preferences regarding medical interventions to use in a terminal condition, irreversible coma, or persistent vegetative state with no hope of recovery. Employees of the health care facility should not sign as witnesses; therefore, the nurse cannot sign as witness. Refusing a client may not be a good communication method; instead, the nurse could politely indicate the reason for declining.
A client with chronic obstructive pulmonary disease presents with respiratory acidosis and hypoxemia. He tells the nurse that he doesn't want to be placed on a ventilator. What action should the nurse take?
Notify the physician immediately so he can determine client competency. Explanation: Three requirements are necessary for informed decision-making: the decision must be given voluntarily; the client making the decision must have the capacity and competence to understand; and the client must be given adequate information to make the decision. In light of the client's respiratory acidosis and hypoxemia, the client might not be competent to make this decision. The physician should be notified immediately so he can determine client competency.
The nurse is caring for several neonates in the newborn nursery. Precautions that should be taken to prevent an infant abduction include which of the following?
Notifying the hospital's security staff about anyone who appears unusual Explanation: The nurse should notify the hospital's security staff about anyone who appears unusual.
During a bedside shift report, the nurse finds that the client is receiving the wrong IV solution. Which action by the nurse is indicated?
Write up an incident report describing the error Explanation: After starting the correct solution, the nurse should complete an incident report describing the specific error. The healthcare provider should be notified as well as the nurse manager; however, if the manager is not present and the error corrected, notification may take place after the report is complete.
A client with acute kidney failure is placed on fluid restriction of 1000 mL of fluid over a 24-hour period. What is the priority nursing action?
Offer the client proportioned fluids in the day and less during the night. Explanation: The client and nurse should make a fluid schedule that takes into consideration factors such as periods of wakefulness, number of meals, oral medications, and personal preferences. Avoiding night fluids will decrease risk for aspiration.
In many institutions, which of the following telephone or fax orders requires a signature within 24 hours by the ordering physician or nurse practitioner?
Orders for antibiotics. Explanation: Many institutional policies dictate that orders for restraints, narcotics, anticoagulants, and antibiotics require the ordering physician or nurse practitioner to sign the order within 24 hours.
A nurse is developing a care plan for a client with disseminated intravascular coagulation (DIC). Which nursing intervention should the nurse include?
Place a pressure-reducing mattress on the client's bed. Explanation: A client with DIC is at risk for Impaired skin integrity related to bleeding or ischemia. The nurse should place the client on a pressure-reducing mattress and perform skin care every 2 hours. The nurse should avoid administering any medication that decreases platelet function, such as aspirin.
A breastfeeding client is seen at home by the visiting nurse 10 days after a vaginal birth. The client is reporting a warm, red, painful breast, a temperature of 100° F (37.7°C), and flulike symptoms. What should the nurse do?
Refer the woman to her health care provider (HCP). Explanation: The client is exhibiting signs and symptoms of a breast infection (mastitis). The nurse should instruct her to contact her HCP, who will likely prescribe a prescription for antibiotics. She should continue to breastfeed the infant from both breasts. Frequent breastfeeding is encouraged rather than discontinuing the process for anyone having a breast infection.
Two parents who are arguing in their infant's room, with voices raised and getting louder, start to hit each other. The infant is crying. Which of the following actions should the staff nurse take next?
Remove the infant from the room. Explanation: The situation is escalating, and the nurse's priority is to protect the infant from harm. Therefore, removal of the infant from this situation should be the first action by the nurse.
A registered nurse (RN) instructs the unlicensed assistive personnel (UAP) to check the urine intake and output (I&O;) on clients on the oncology unit at the end of the 8-hour shift. It is important for the nurse to instruct the UAP to do what?
Report back to the nurse immediately if any client has an output less than 240 mL. Explanation: The RN is responsible for describing to the UAP when to report to the RN a result that indicates a potential client problem with dehydration. The RN must assess and interpret results, but must give concrete feedback to the UAP on what is an expected situation or a specific result to report back to the RN. Urine output should be at least 30 mL/h, or 240 mL over the 8-hour shift.
An elderly client who has been diagnosed with delusional disorder for many years is exhibiting early symptoms of dementia. His daughter lives with him to help him manage daily activities, and he attends a day care program for seniors during the week while she works. A nurse at the day care center hears him say, "If my neighbor puts up a fence, I will blow him away with my shotgun. He has never respected my property line, and I have had it!" Which action should the nurse take? a) Report the comment to the neighbor, the daughter, and the police since there is the potential for a criminal act. b) Observe the client more closely, but do not report his threat since he will likely not be able to follow through with it because of his dementia. c) Report the comment to the neighbor, the intended victim, but refrain from telling the daughter since she will just worry about actions of her father she cannot control. d) Rep
Report the comment to the neighbor, the daughter, and the police since there is the potential for a criminal act. Correct Explanation: The neighbor could be harmed as well as the daughter if she should try to stop her father from using the gun, so both should be notified. Any use of firearms against another person requires the involvement of the police. The nurse has a legal/ethical responsibility to warn potential victims and other involved parties as well as law enforcement authorities when one person makes a threat against another person. This duty supersedes confidentiality statutes. Failure to do so and to document it can result in civil penalties.
While giving report to the oncoming night shift, the charge nurse smells alcohol on the breath of one of the nurses. The charge nurse should:
Report this to the nursing supervisor immediately Explanation: This situation should be reported immediately to the nursing supervisor or manager at the time. The nurse is liable to report a suspicious situation that could create an unsafe situation for the clients. Reporting a suspicious situation does not imply actual guilt; it implies identification of a high-risk situation. The supervisor will then follow the correct procedure for management and follow-up of the situation.
A usually reliable interpreter called by the nurse to help communicate with a mother of a child who does not speak English and has brought her child in for a routine visit has yet to arrive in the clinic. The nurse has paged the interpreter several times. Which of the following should the nurse do next?
Reschedule the infant's appointment for later in the week. Explanation: The interpreter may have been delayed. Therefore, the nurse's best action would be to reschedule the child's appointment when the interpreter can be scheduled as well. Because the mother does not speak English, there is no point in examining the infant because history information is needed and most likely would be too difficult to obtain.
The nurse finds a sealed container of I.V. 50% dextrose in a waste bin on the nursing unit. The nurse should:
Send it to the pharmacy. Explanation: The nurse should send the sealed container of I.V. 50% dextrose found in the catch-all bin to the pharmacy. A concentrated medication such as 50% dextrose could be lethal if inadvertently administered and should not be stored outside the pharmacy.
A 42-year-old client was admitted from a homeless shelter with a diagnosis of tuberculosis and alcoholism. It is essential that which of the following health care team members attend the care conference to discuss discharge planning and community resources?
Social worker. Explanation: The social worker is the most essential team member to be involved in discharge planning to meet the client's needs and offer suggestions for the best community resources
A nurse overhears a fellow staff member talking about the mother of a child for whom the staff nurse is caring. The nurse is telling others private information that the mother had shared. Which of the following responses by the nurse overhearing the conversation would be best?
Talking to the staff member privately about this. Explanation: The best approach is to talk to the staff member privately about the information that the mother shared. This information is confidential and should not be disclosed. Reporting the incident to the nurse-manager is appropriate once the nurse has spoken to the staff member privately
A nurse who is a case manager is responsible for assigning client care to unregulated care providers (UCPs). The nurse is planning the care for a new client who requires several treatments. Which of the following UCPs should the nurse assign to the new client?
The UCP with the appropriate knowledge and skills to provide the care Explanation: The nurse is accountable for the assignment of tasks to UCPs. The nurse must ensure that the care being assigned is consistent with the UCP's level of knowledge, skill, and judgment. Assignments must also consider the UCP job description, agency policy, legislation, and client need.
The nurse's unit council in the telemetry unit is responsible for performance improvement studies. What information should they gather to study whether client education about resuming sexual activity after an acute myocardial infarction (MI) is being taught?
The percentage of clients on the unit diagnosed with an acute MI who were taught about resuming sexual activity Explanation: The unit council needs to assess the number of clients diagnosed with an acute MI on the telemetry unit who were actually taught about resuming sexual activity. The unit council needs to identify the number of clients who were taught, not the quality of the teaching. Only education about resuming sexual activity is pertinent to this performance improvement study.
A client is admitted to an inpatient psychiatric unit. After the assessment and admission procedures have been completed, the nurse states, "I'll try to be available to talk with you when needed and will spend time with you each morning from 10:00 until 10:30 in the corner of the dayroom." What is the rationale for communicating these planned nursing interventions?
To attempt to establish a trusting relationship Explanation: Availability, reliability, and consistency are critical factors in establishing trust with a client. Being specific about the time and place of meetings helps establish trust, which is initially the main objective.
Thirty people are injured in a train derailment. Which client should be transported to the hospital first?
a 25-year-old with a sucking chest wound Explanation: During a disaster, the nurse must make difficult decisions about which persons to treat first. The guidelines for triage offer general priorities for immediate, delayed, minimal, and expectant care. The client with a sucking chest wound needs immediate attention and will likely survive.
While providing care for a hospitalized infant, a nurse is summoned to the phone. The caller requests information about the infant's condition. The nurse should: a) determine the caller's identity before responding. b) update the caller in the interest of good public relations. c) transfer the call to the infant's room. d) protect the infant's confidentiality by divulging no information to the caller.
determine the caller's identity before responding. Correct Explanation: The nurse must identify the caller before giving information or refusing to give information. Client confidentiality is mandatory and isn't negated by the concept of public relations. The caller's identity and relationship to the infant may make it appropriate for the nurse to divulge information over the phone.
A nurse may delegate adding medications to I.V. fluid containers to a:
pharmacist Explanation: A nurse should delegate the task of adding medications to primary fluid containers to a pharmacist
A nurse is providing care for a client who underwent mitral valve replacement. The best example of a measurable client outcome goal is for the client to: a) walk from his room to the end of the hall and back before discharge. b) select special foods from a diet after client education by the nurse. c) change his own dressing with clean technique and be able to verbalize the steps. d) walk with help in the hallway by the end of the evening shift.
walk from his room to the end of the hall and back before discharge. Explanation: Walking from the client's room to the end of the hall and back before discharge is a specific, measurable, attainable, and timed goal. It's also a client-oriented outcome goal. Having the client change his own dressing is incomplete and not as significant. Just walking in the hall isn't measurable. T
Which of the responsibilities related to the care of a client with a Foley catheter are appropriate for the nurse to delegate to the unlicensed assistive personnel (UAP)? Select all that apply.
• Ensure the urine drainage bag is below the level of the bladder at all times. • Empty drainage bag, and record output at specified times. • Provide Foley catheter and perineal care each shift. • Apply catheter-securing device to the client's leg. Explanation: While the scope of practice for a UAP may vary by state, province, or territory, as well as by place of employment, general duties include recording input and output, including emptying and recording urine output from a Foley catheter. A UAP with proper training may apply a securing device to maintain safety, provide regular Foley catheter and perineal care and ambulate a client with a catheter, continually monitoring that the collection bag remains below the level of the bladder to help prevent infection.
A client is admitted with numbness and tingling of the feet and toes after having an upper respiratory infection and flu for the past 5 days. Within 1 hour of admission, the client's legs are numb all the way up to the hips. The nurse should do which of the following next? Select all that apply.
• Place respiratory resuscitation equipment in the client's room. • Check for advancing levels of paresthesia. • Notify the health care provider of the change. Explanation: A client who has been admitted for numbness and tingling in his lower extremities that advances upward, especially after having a viral infection, has clinical manifestations characteristic of Guillain-Barré syndrome. The health care provider must be notified of the change immediately because this disease is progressively paralytic and should be treated before paralysis of the respiratory muscles occurs. The nurse must assess the client continuously to determine how fast the paralysis is advancing.
The nurse assigns an unlicensed assistive personnel (UAP) to care for a client who is 1 day postpartum. Which tasks would be appropriate to delegate to this person? Select all that apply.
• changing the perineal pad and reporting the drainage • reinforcing good hygiene while assisting the client with washing the perineum • assisting the client with ambulation shortly after birth Explanation: Delegating care to UAP requires that the nurse knows which tasks are within that individual's capability. Changing the perineal pad and reporting drainage, reinforcing hygiene with perineal care, and assisting with ambulation are within the individual's capacity. UAP should never be asked to complete any assessments, such as checking fundal location or performing skilled procedures on a client. In addition, it would be beyond the scope of the job of UAP to conduct client teaching such as teaching the mother how to latch or discussing postpartum depression with the client.
The charge nurse in the newborn nursery has an unlicensed assistive personnel (UAP) with her for the shift. Under their care are 8 babies rooming in with their mothers, and 1 infant in the nursery for the night on tube feedings. There is a new client whose infant will be brought to the nursery in 15 minutes. Which tasks would the nurse assign to the UAP? Select all that apply.
• document feedings of infants • record voids/stools • vital signs on all stable infants Explanation: The role of the UAP allows this member of the health care team to take vital signs on clients, record feedings, and voids and stools of infants according to hospital guidelines.
An airplane crash results in mass casualties. The nurse is directing personnel to tag all victims. Which information should be placed on the tag? Select all that apply.
• triage priority • medications and treatments administered • identifying information when possible (such as name, age, and address) Explanation: Tracking victims of disasters is important for casualty planning and management. All victims should receive a tag, securely attached, that indicates the triage priority, any available identifying information, and what care, if any, has been given along with time and date. Tag information should be recorded in a disaster log and used to track victims and inform families.
A 9-month-old is admitted because of dehydration. How should the nurse go about accurately monitoring fluid intake and output? Select all that apply. a) obtaining an accurate stool count b) changing breastfeedings to bottle-feedings c) weighing and recording all wet diapers d) obtaining an accurate daily weight e) restricting fluids prior to weighing the child
• weighing and recording all wet diapers • obtaining an accurate daily weight • obtaining an accurate stool count Explanation: Accurate intake and output recording includes noting all intake, including IV fluids; noting output, such as emesis and stool; weighing diapers; measuring weight daily; measuring urine specific gravity; monitoring serum electrolytes; and monitoring for signs of dehydration. Children who are dehydrated must receive sufficient fluid intake, but having a breast-feeding child switch to bottle-feeding will not promote intake.
