A nurse is caring for a 7-year-old child who has severe dehydration. Which of the following findings should the nurse expect?
Blood pressure 94/68 mm Hg
Urinary output 30 mL/hr
Respiratory rate 24/min
Heart rate 152/min
The Correct Answer is D
A. A blood pressure of 94/68 mm Hg is within the normal range for a 7-year-old child and may indicate compensated dehydration rather than severe dehydration.
B. A urinary output of 30 mL/hr is insufficient and may indicate dehydration, but it does not specifically indicate severe dehydration.
C. A respiratory rate of 24/min is within the normal range for a 7-year-old child and is not specifically indicative of severe dehydration.
D. Tachycardia (heart rate >100 beats per minute) is a common finding in severe dehydration as the body attempts to compensate for decreased blood volume by increasing heart rate.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Limit each of the client's visitors to 1 hr per day. - This is not necessary specifically due to the presence of the radiation implant. Visitation restrictions should be based on hospital policy and
the client's condition, not solely on the presence of a radiation implant.
B. Remove dirty linens from the room after double bagging. - This is a standard infection control measure and is not specific to caring for a client with a radiation implant.
C. Wear a dosimeter film badge while in the client's room. - Healthcare workers who care for clients with sealed radiation implants should wear dosimeter film badges to monitor their radiation exposure levels.
D. Ensure family members remain at least 1 m (3.2 feet) from the client. - While limiting exposure to radiation is important, maintaining distance alone may not provide adequate
protection. Healthcare workers should follow appropriate safety precautions and use shielding as necessary when caring for clients with radiation implants.
Correct Answer is A
Explanation
A.
A. Visible contusions on all four extremities may indicate physical abuse, especially in the context of being brought to the emergency department by a family member. Reporting the
incident to Adult Protective Services is essential to ensure the safety and well-being of the client.
B. Interviewing the client with his adult child present may not be appropriate if there are concerns about potential abuse or coercion.
C. Forcing the client to answer every assessment question may not be appropriate if the client is in distress or unable to communicate freely.
D. Advising the client to consult a social worker may be appropriate, but reporting suspected abuse to Adult Protective Services is the priority action in this situation.
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