A nurse is assisting with the care of a 2-year-old child.
Select the 6 findings that require immediate follow-up.
Bowel elimination
Oxygenation
Respiratory rate
Temperature
Hgb
Sodium
Blood pressure
Skin turgor
Creatinine
Correct Answer : A,D,E,G,H,I
A. Bowel elimination: The child has had six watery stools in 24 hours with confirmed Escherichia coli infection, indicating ongoing significant gastrointestinal fluid losses. Continued diarrhea increases the risk of worsening dehydration, electrolyte imbalance, and hypovolemia, especially in a 2-year-old with limited physiologic reserves.
B. Oxygenation: Oxygen saturation has remained between 95% and 98% on room air, which is within acceptable limits for a toddler. There is no evidence of respiratory distress or hypoxemia requiring urgent intervention based on the data provided.
C. Respiratory rate: A respiratory rate of 25–30/min falls within the upper expected range for a 2-year-old, particularly in the presence of fever. There is no indication of severe tachypnea or respiratory compromise requiring immediate follow-up.
D. Temperature: The child’s temperature increased to 38.8°C (101.8°F) on Day 2, indicating persistent or worsening infection. Ongoing fever in the setting of confirmed E. coli and dehydration increases metabolic demand and fluid loss, requiring prompt reassessment and management.
E. Hgb: Hemoglobin of 16 g/dL is elevated for age and suggests hemoconcentration secondary to dehydration. Fluid loss from vomiting and diarrhea reduces plasma volume, artificially elevating hemoglobin concentration, which signals significant intravascular volume depletion.
F. Sodium: Sodium level of 136 mEq/L falls within the normal reference range. There is no current laboratory evidence of hypo- or hypernatremia requiring urgent correction.
G. Blood pressure: Blood pressure readings of 95/56–98/62 mm Hg in a toddler with ongoing fluid loss raise concern for evolving hypovolemia. Although not profoundly hypotensive, the combination of tachycardia, dehydration signs, and weight loss suggests risk for progression to hypovolemic shock.
H. Skin turgor: Delayed skin turgor and sunken eyes are classic clinical signs of moderate to severe dehydration in pediatric clients. These findings reflect decreased interstitial fluid volume and require immediate intervention to prevent further hemodynamic instability.
I. Creatinine: Creatinine of 0.8 mg/dL is elevated for a 2-year-old, indicating possible decreased renal perfusion due to dehydration. Reduced intravascular volume can impair glomerular filtration rate, placing the child at risk for acute kidney injury.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. "Extension cords can be placed under floor mats.": Placing cords under floor mats is unsafe because it increases the risk of overheating, fraying, and fire. It also creates a tripping hazard. Proper cord management involves keeping cords visible and free from pressure or obstructions.
B. "Paper tape should be used to secure extension cords to the floor.": Paper tape is not durable enough to secure cords and can easily tear, increasing the risk of tripping or cord damage. Only heavy-duty tape or cable covers specifically designed for electrical safety should be used.
C. "Electrical items should be unplugged by grasping and pulling on the cord.": Pulling on the cord can damage wiring and increase the risk of electric shock or fire. Items should always be unplugged by gripping the plug itself to maintain cord integrity and safety.
D. "Electrical items should be disconnected before cleaning them.": Disconnecting electrical devices before cleaning prevents accidental activation and reduces the risk of electric shock. This is a fundamental principle of electrical safety in healthcare and demonstrates correct understanding of safe practices.
Correct Answer is B
Explanation
A. Discontinue the enema: Mild cramping is a common response during enema administration and does not require stopping the procedure. Discontinuing unnecessarily would prevent the client from receiving the intended therapeutic effect.
B. Slow the rate of instillation: Cramping often occurs when the solution enters the rectum too quickly. Slowing the rate allows the colon to accommodate the fluid more comfortably, reducing discomfort while continuing the enema safely and effectively.
C. Ask the client to hold his breath until the cramping passes: Holding the breath does not relieve rectal cramping and may increase client discomfort or anxiety. Comfort measures should focus on adjusting the procedure rather than altering breathing inappropriately.
D. Pause the enema to administer pain medication to the client: Administering systemic pain medication is unnecessary for mild, transient cramping. Slowing the enema is sufficient to manage discomfort, and pausing for medication would unnecessarily delay treatment.
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