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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?

A.

Heart rate 148/min

B.

Potassium 3.9 mEq/L

C.

Respiratory rate 22/min

D.

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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Related Questions

Correct Answer is C

Explanation

A. Warm skin – Hypoglycemia typically presents with cool, clammy skin due to vasoconstriction, not warm skin.

B. Tachypnea – Tachypnea is a sign of diabetic ketoacidosis (DKA), which occurs with hyperglycemia, not hypoglycemia.

C. Nervousness – This is the correct answer because hypoglycemia triggers the release of epinephrine, leading to symptoms such as nervousness, tremors, sweating, and palpitations.

D. Ketonuria – Ketonuria is associated with DKA, which occurs in severe hyperglycemia, not hypoglycemia.

Correct Answer is B

Explanation

A. Hold a vibrating tuning fork 1 to 2 cm (0.4 to 0.8 in) from the child's ears – This describes the Rinne test, not the Weber test.

B. Place a vibrating tuning fork on the top of the child's head – Correct. The Weber test assesses hearing loss by placing a tuning fork on the midline of the skull to determine if sound is heard equally in both ears.

C. Whisper a statement to the child from 0.6 m (2 feet) away – This describes the whisper test, not the Weber test.

D. Apply a pair of headphones securely over the child's ears – Not part of the Weber test; this is used for audiometry testing.

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