The nurse is caring for an infant with a suspected urinary tract infection. Which clinical manifestations should be expected? (Select all that apply.)

Correct Answer: A

Rationale: A urinary tract infection (UTI) in an infant may present with symptoms such as vomiting and failure to gain weight. Vomiting can be a common sign of UTI in infants due to irritation and inflammation in the urinary tract. Additionally, infants with UTIs may experience poor feeding and failure to gain weight due to the discomfort and systemic effects of the infection. While symptoms like jaundice, swelling of the face, back pain, and persistent diaper rash can be seen in other conditions, they are not typically associated with a urinary tract infection in infants.

Correct Answer: A

Rationale: Infection is the leading cause of death after heart transplantation. Following transplantation, patients are at a higher risk of infections due to the immunosuppressive medications they must take to prevent organ rejection. These medications suppress the immune system's responses, leaving the patient susceptible to various infections such as bacterial, viral, and fungal infections. Without timely diagnosis and treatment, these infections can lead to serious complications and even death in heart transplant recipients. Therefore, the careful monitoring and management of infections are crucial in post-transplant care to improve outcomes and prevent mortality.

Correct Answer: B

Rationale: Recording the color of drainage from each tube and catheter is crucial in the nursing care plan as it provides a means for further comparison and evaluation. Changes in the color of drainage can indicate potential issues such as infection, bleeding, or other complications post-surgery. By monitoring the color of drainage, the nurse can identify any abnormal changes early on and take appropriate actions to address them promptly. This practice helps in assessing the patient's condition and ensuring optimal recovery and healing after the surgery.

Correct Answer: C

Rationale: When a client undergoes treatment for a malignant tumor requiring a urinary diversion procedure, such as a urostomy, it is crucial for nurses to closely monitor for any signs of leakage of urine or stool from the anastomosis site. This is important because it can indicate complications such as infection, poor wound healing, or a breakdown in the surgical site. Detecting and addressing leakage promptly can help prevent further complications and ensure the client's recovery progresses smoothly. While the other options may be important aspects of nursing care, observing for leakage of urine or stool from the anastomosis is the most critical factor in managing clients undergoing treatment for a malignant tumor affecting the urinary system.

Correct Answer: A

Rationale: The patient's presentation suggests that he may be suffering from hypermagnesemia (high magnesium levels) due to excessive ingestion of antacid tablets. Symptoms of hypermagnesemia can include flushing, weakness, and low blood pressure. A serum magnesium level of 11mEq/L is consistent with hypermagnesemia. In this scenario, the other values (2mEq/L, 5mEq/L, 1mEq/L) are unlikely to be the correct magnesium level based on the patient's symptoms and history of antacid ingestion.