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
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).
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
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.
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.
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