A nurse is caring for a 3-year-old toddler who has dehydration. Which of the following findings should the nurse report to the provider?

Heart rate 148/min

Potassium 3.9 mEq/L

Respiratory rate 22/min

Sodium 142 mEq/L

Answer and Explanation

The Correct Answer is A

A. Heart rate 148/min – Correct. A heart rate of 148/min in a 3-year-old is elevated (tachycardia) and may indicate worsening dehydration or shock.

B. Potassium 3.9 mEq/L – Incorrect. This potassium level is within the normal range (3.5–5.0 mEq/L).

C. Respiratory rate 22/min – Incorrect. This is within the expected range for a 3-year-old.

D. Sodium 142 mEq/L – Incorrect. This sodium level is within the normal range (135–145 mEq/L).

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Correct Answer is A

Explanation

A. "I'll place him in the back seat facing the back seat." – This is the correct answer. Infants should always ride in a rear-facing car seat in the back seat until at least 2 years of age.

B. "I'll place him in the front seat facing the front of the car." – The front seat is not safe for infants due to airbag deployment risks.

C. "I’ll place him in the back seat facing the back of the front seat." – This wording is unclear, but the safest position is directly facing the back of the car.

D. "I’ll place him in the front seat facing the back of the car.” – Infants should not be placed in the front seat, even if rear-facing.

A. Infuse the transfusion over 5 hr. B. Hang the transfusion with dextrose 5% in 0.9% sodium chloride. C. Use a 20-gauge IV catheter to transfuse the blood. D. Monitor vital signs every hour throughout the transfusion.

Correct Answer is A

Explanation

A. This is the correct answer. Older adults are at risk for fluid overload, so infusing blood over 4-5 hours (instead of the usual 2-4 hours) is safer.

B. Blood products must be infused with 0.9% sodium chloride (normal saline) only. Dextrose-containing solutions cause hemolysis.

C. A 20-gauge catheter is acceptable, but a larger bore (18-gauge) is preferred for faster infusion.

D. Vital signs should be monitored before the transfusion, 15 minutes after starting, then every 30-60 minutes, and at completion.

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A nurse is caring for a 3-year-old toddler who has dehydration. Which of the following findings should the nurse report to the provider?

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