A nurse is assisting with the care of a 2-year-old child.
Click to highlight the findings that indicate the child has progressed. To deselect a finding, click on the finding again.
Day 3, 0900:
Weight
Bowel pattern
Sodium level
Respiratory rate
Urine specific gravity
Skin turgor
Heart rate
Weight
Bowel pattern
Sodium level
Respiratory rate
Urine specific gravity
Skin turgor
Heart rate
The Correct Answer is ["A","B","E","F","G"]
Rationale for correct choices:
• Weight: The child’s weight increased from 9.5 kg on day 2 to 10.2 kg on day 3, surpassing the admission weight of 10 kg. This indicates successful rehydration and restoration of fluid balance. Weight gain is a reliable objective marker of improvement in pediatric dehydration.
• Bowel pattern: The child’s stools changed from six watery stools on day 2 to two formed stools on day 3. This reflects resolution of diarrhea and recovery of gastrointestinal function. Normalization of bowel movements indicates that electrolyte and fluid losses have been addressed effectively.
• Urine specific gravity: Urine specific gravity decreased from 1.031 on admission to 1.018 on day 3. This reflects improved hydration status and kidney perfusion, as urine is less concentrated. Monitoring urine concentration helps evaluate the effectiveness of fluid replacement therapy.
• Skin turgor: Skin turgor improved from 2 seconds to less than 1 second and appears consistent with the child’s baseline. This indicates restored hydration and effective fluid therapy. Normal skin turgor demonstrates recovery from extracellular fluid deficit.
• Heart rate: The heart rate decreased from a tachycardic 116/min on Day 2 to 100/min on Day 3. A stable, lower heart rate indicates that the circulatory volume is adequate and the heart no longer needs to overcompensate for low blood volume.
Rationale for incorrect findings:
• Sodium level: Sodium remained within normal range (138 mEq/L), so while stable, it does not specifically indicate improvement beyond baseline.
• Respiratory rate: Respiratory rate remained mildly elevated at 26 breaths/minute; it shows stability but does not directly indicate recovery from dehydration.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. 2+ deep tendon reflex: A reflex rating of 2+ is normal and indicates adequate neuromuscular function. In a client receiving magnesium sulfate, this suggests that magnesium levels are within the therapeutic range and are not causing toxicity.
B. Facial flushing: Facial flushing is a common side effect of magnesium sulfate due to vasodilation. While uncomfortable, it is not dangerous and typically does not require intervention unless accompanied by other signs of toxicity.
C. Respiratory rate 13/min: A respiratory rate above 12/min is generally considered within normal limits for adults. Magnesium toxicity becomes concerning when the respiratory rate drops below 12/min, indicating central nervous system depression.
D. Urine output 20 mL/hr: Magnesium sulfate is excreted primarily by the kidneys, and low urine output (<30 mL/hr) increases the risk of magnesium accumulation and toxicity. Reporting this finding allows the provider to adjust the infusion rate or evaluate renal function to prevent serious complications.
Correct Answer is B
Explanation
A. Report the location of the fire: Notifying appropriate personnel or the fire alarm system is important for mobilizing help and initiating emergency response. However, it is not the first action because immediate threats to client safety must be addressed before communication.
B. Protect clients from immediate injury: The priority in any fire situation is the safety of clients and staff. Removing clients from immediate danger or shielding them from harm takes precedence over reporting, containing, or extinguishing the fire. This aligns with the first step of the RACE protocol (Rescue) in fire safety.
C. Contain the fire to one area: Containing the fire by closing doors and windows is critical to prevent spread, but it follows after ensuring that clients and staff are safe from immediate harm. Containment cannot protect individuals already in danger.
D. Extinguish the fire if possible: Extinguishing a fire is part of the RACE protocol, but attempting to put out a fire is secondary to rescuing individuals at risk. Only small, controllable fires should be attempted after ensuring safety of clients and staff.
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