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 D

Explanation

A. Prednisone should be taken with food to reduce gastrointestinal irritation.

B. Aspirin increases the risk of GI bleeding when taken with prednisone.

C. Prednisone doses should be increased, not reduced, during stress to prevent adrenal insufficiency.

D. This is the correct answer. Weight-bearing exercises like walking help reduce the risk of osteoporosis, a side effect of long-term prednisone use.

A. Empty the collection chamber every 8 hr. B. Check the patency of the tubing every 2 hr. C. Keep the drainage system above the level of the client's chest. D. Ensure 2 cm (0.8 in) of water is in the water seal chamber.

Correct Answer is D

Explanation

A. Empty the collection chamber every 8 hr – Incorrect. The collection chamber is not emptied; instead, it is replaced when full to prevent air re-entry.

B. Check the patency of the tubing every 2 hr – While monitoring the tubing is essential, checking patency is not the most specific nursing priority.

C. Keep the drainage system above the level of the client's chest – Incorrect. The system should remain below chest level to prevent backflow of drainage.

D. Ensure 2 cm (0.8 in) of water is in the water seal chamber – Correct. The water seal chamber maintains negative pressure and prevents air from entering the pleural space, making this a crucial step in chest tube management.

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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?

Nursing Test Bank

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