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?
Sodium 142 mEq/L.
Respiratory rate 22/min.
Potassium 3.9 mEq/L.
Heart rate 148/min.
The Correct Answer is D
Choice A rationale:
Sodium level of 142 mEq/L is within the normal range (135-145 mEq/L) for adults. However, normal ranges for children might vary slightly, but 142 mEq/L is not indicative of dehydration on its own.
Choice B rationale:
Respiratory rate of 22/min is within the normal range for a 3-year-old child (20-30 breaths/min) This rate alone does not provide evidence of dehydration.
Choice C rationale:
Potassium level of 3.9 mEq/L is within the normal range (3.5-5.1 mEq/L) for children. Like sodium, normal ranges for potassium may differ slightly in pediatric patients, but 3.9 mEq/L is not alarming on its own.
Choice D rationale:
Heart rate of 148/min is elevated for a 3-year-old child. Tachycardia is a common sign of dehydration in pediatric patients. This increased heart rate indicates the body's compensatory mechanism to maintain cardiac output in response to decreased blood volume, a typical consequence of dehydration.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A - This is correct because discomfort while walking can indicate genital trauma or infection, which are possible signs of sexual abuse.
B - This is incorrect because thin extremities can be caused by many factors, such as malnutrition, genetic disorders, or chronic diseases, that are not necessarily related to sexual abuse.
C - This is incorrect because bruises on the upper back can result from accidental injuries, such as falls or bumps, or from physical abuse, such as hitting or kicking, but not specifically from sexual abuse.
D - This is incorrect because a stained shirt can be due to poor hygiene, food spills, or environmental factors, but not necessarily from sexual abuse.
Correct Answer is A
Explanation
Choice A rationale:
A blood lead level of 18 mcg/dL in a 9-month-old infant is elevated. The Centers for Disease Control and Prevention (CDC) considers a blood lead level of 5 mcg/dL or higher in children to be concerning. Lead exposure can lead to developmental delays and cognitive impairments. Therefore, this result needs to be reported to the healthcare provider promptly.
Choice B rationale:
Hemoglobin level of 12 g/dL is within the normal range for a 9-month-old infant (11-15 g/dL) There is no need to report this result to the provider.
Choice C rationale:
Iron level of 74 mcg/dL is within the normal range for a 9-month-old infant (50-120 mcg/dL) There is no need to report this result to the provider.
Choice D rationale:
Hematocrit level of 35% is within the normal range for a 9-month-old infant (29-41%) There is no need to report this result to the provider.
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