A 3-month-old is admitted with severe diarrhea. Yesterday, the infant weighed 11 pounds (5 kg). Today, this infant weighs 9 pounds, 8 ounces (4.3 kg). Based on this information, the nurse documents that the infant has:
Failure to thrive.
Malabsorption syndrome.
Severe dehydration.
Risk for fluid volume deficit.
The Correct Answer is C
Choice A rationale
Failure to thrive is a condition where a child does not gain weight or grow as expected. While severe diarrhea can contribute to failure to thrive, the immediate concern in this scenario is the significant weight loss indicating severe dehydration.
Choice B rationale
Malabsorption syndrome involves the inability to absorb nutrients properly, leading to malnutrition and weight loss. However, the acute weight loss in this case is more indicative of severe dehydration.
Choice C rationale
Severe dehydration is characterized by significant fluid loss, which can be life-threatening in infants. The weight loss from 11 pounds to 9 pounds, 8 ounces indicates a substantial fluid loss, pointing to severe dehydration.
Choice D rationale
Risk for fluid volume deficit is a potential diagnosis, but the significant weight loss and clinical presentation indicate that the infant is already experiencing severe dehydration.
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Correct Answer is B
Explanation
Choice A rationale
Insulin should be administered subcutaneously, not intramuscularly. Rotating sites is important to prevent lipodystrophy, but the correct technique involves subcutaneous injection.
Choice B rationale
Drawing up the short-acting insulin into the syringe first is correct. This prevents contamination of the short-acting insulin vial with long-acting insulin, ensuring accurate dosing.
Choice C rationale
Wiping off the needle with an alcohol swab is not recommended. The needle should remain sterile, and only the top of the insulin vial should be wiped with an alcohol swab.
Choice D rationale
Administering insulin at a 30-degree angle is incorrect. Insulin should be administered at a 90- degree angle if the person can grasp 2 inches of skin, or at a 45-degree angle if only 1 inch of skin can be grasped.
Correct Answer is C
Explanation
Choice A rationale
Budesonide via dry-powder inhaler is a corticosteroid used for long-term control of asthma. It is not effective for immediate relief of acute asthma exacerbations.
Choice B rationale
Cromolyn via metered-dose inhaler is a mast cell stabilizer used for long-term control of asthma. It is not effective for immediate relief of acute asthma exacerbations.
Choice C rationale
Albuterol via jet nebulizer is a short-acting beta-adrenergic agonist that provides rapid bronchodilation. It is the medication of choice for immediate relief of acute asthma exacerbations.
Choice D rationale
Montelukast orally is a leukotriene receptor antagonist used for long-term control of asthma. It is not effective for immediate relief of acute asthma exacerbations.