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. Implement NPO status: Clients with urolithiasis typically do not require NPO status unless they are scheduled for surgery or a procedure. Restricting oral intake unnecessarily can lead to dehydration, which may worsen stone formation or impede stone passage.
B. Place the client on bedrest: Ambulation is encouraged for clients with urolithiasis to promote urinary flow and facilitate passage of stones. Bedrest is generally not indicated unless there are complications, so restricting mobility could hinder stone expulsion.
C. Monitor the client's liver function: Liver function tests are not routinely affected by urolithiasis. Monitoring liver enzymes is unnecessary unless there is a separate hepatic condition or if the client is on medications that affect the liver.
D. Strain the client's urine: Straining urine allows for collection of passed stones, which can then be analyzed to determine stone composition. This information guides dietary recommendations, pharmacologic interventions, and prevention strategies for future stone formation.
Correct Answer is B
Explanation
A. The client's foot feels cooler than in the previous assessment: A cooler extremity following vascular surgery can indicate decreased perfusion, but temperature alone is a subjective and late indicator. It must be interpreted in conjunction with pulses, capillary refill, color, and pain. While concerning, it does not provide definitive evidence of acute graft compromise by itself.
B. The client's pedal pulse in the right foot is not palpable: Absence of a distal pedal pulse following a femoropopliteal bypass graft raises immediate concern for graft occlusion or acute arterial thrombosis. Patency of the graft is essential to restore blood flow to the lower extremity, and loss of pulse indicates potential ischemia.
C. The client's capillary refill time is 5 seconds in the toes: A prolonged capillary refill suggests impaired peripheral perfusion, but it is less specific than pulse assessment. Capillary refill can be influenced by environmental temperature and vasoconstriction. While abnormal, it is not as critical as the absence of a palpable pulse in evaluating graft function.
D. The client reports a pain level of 8 on a scale from 0 to 10: Postoperative pain is expected after a vascular surgical procedure and may be significant. However, pain must be correlated with other ischemic signs such as pulselessness, pallor, paresthesia, and paralysis to determine severity. Severe pain alone, without objective perfusion deficits, is not the most urgent finding.
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