A nurse is caring for a toddler admitted to the hospital.
Click to highlight the findings that require immediate follow-up. To deselect a finding, click on the finding again.
|
Body Systems |
Findings |
|
Respiratory |
Respiratory rate 26/min |
|
Cardiovascular |
Heart rate 112/min Capillary refill 4 seconds |
|
Gastrointestinal |
Hyperactive bowel sounds |
|
Integumentary |
Diaper area reddened with erythema noted Extremities cool Reports no tears |
|
Neurologic |
Lethargic |
Capillary refill 4 seconds
Hyperactive bowel sounds
Diaper area reddened with erythema noted
Extremities cool
Reports no tears
Lethargic
Respiratory rate 26/min
Heart rate 112/min
The Correct Answer is ["A","B","C","D","E","F"]
Capillary refill 4 seconds: A prolonged capillary refill time of more than 2 seconds may indicate poor perfusion, possibly due to dehydration or circulatory compromise. This warrants immediate follow-up to assess for potential dehydration or shock.
Hyperactive bowel sounds: This may indicate gastrointestinal distress, such as diarrhea or irritation.
Diaper area erythema: Diaper rash is common in toddlers, particularly with diarrhea. Extremities cool: Cool extremities can be a sign of poor peripheral circulation, often associated with dehydration or developing hypovolemic shock. Immediate intervention is needed to address potential circulatory issues.
Reports no tears: The absence of tears, especially in a toddler, may suggest significant dehydration. This is a concerning sign and requires immediate follow-up to assess the child's hydration status and consider interventions, such as IV fluids or electrolyte management.
Lethargic: The child's lethargy, especially after vomiting and with decreased responsiveness, raises concern for potential dehydration, electrolyte imbalance, or a worsening condition. Lethargy in a toddler requires prompt evaluation and intervention to prevent further deterioration.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Read medication labels at least two times prior to administration: Labels should be read three times (when retrieving, preparing, and administering).
B. Avoid preparing medications for more than two clients at one time: Reduces the risk of medication errors by minimizing task-switching and confusion.
C. Inform clients about the action of each medication prior to administration: While educating clients is essential, it is not always required before every medication.
D. Complete an incident report if a client vomits after taking a medication: An incident report is typically required only for errors or adverse events.
Correct Answer is C
Explanation
A. Assessing IV patency is important but comes after confirming the client is not allergic.
B. Checking compatibility ensures safe administration but is not the first priority.
C. Reviewing the client's allergy history is the priority to prevent a potentially life-threatening allergic reaction.
D. Obtaining the medication is necessary but only after confirming it is safe for the client.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.