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A nurse is caring for an 8-year-old child on an inpatient pediatric unit.

Exhibits
Click to highlight the findings that indicate the client requires immediate follow-up. To deselect a finding, click on the finding again

Body System

Findings

Integumentary

Skin feels cool to the touch.

Capillary refill 3 seconds in left foot

Dressing on left hand shows small amount of moisture through gauze.

Vital Signs

Blood pressure 102/50 mm Hg

Temperature 35.8° C (96.4° F)

Respiratory rate 20/min

Genitourinary

Output of 25 mL dark amber urine through catheter

Skin feels cool to the touch.

Capillary refill 3 seconds in left foot

Dressing on left hand shows small amount of moisture through gauze.

Blood pressure 102/50 mm Hg

Temperature 35.8° C (96.4° F)

Respiratory rate 20/min

Output of 25 mL dark amber urine through catheter

Answer and Explanation

The Correct Answer is ["A","B","D","E","G"]

Rationale for correct choices:

Skin feels cool to the touch: Cool skin indicates poor peripheral perfusion, which can signal early hypovolemic shock in a child with burns. Prompt assessment and interventions, such as fluid resuscitation, are necessary.
Capillary refill 3 seconds in left foot: Delayed capillary refill reflects compromised circulation and decreased tissue perfusion. Early recognition and intervention help prevent progression to shock.
Blood pressure 102/50 mm Hg: Mild hypotension combined with tachycardia, cool skin, and delayed capillary refill suggests early hypovolemic shock, a life-threatening complication requiring immediate attention.
Temperature 35.8° C (96.4° F): Hypothermia can occur due to heat loss from burn injuries, increasing the risk for coagulopathy, impaired wound healing, and further hemodynamic instability.
Output of 25 mL dark amber urine through catheter: Low and concentrated urine output indicates possible dehydration or reduced renal perfusion, which can progress to acute kidney injury if not addressed urgently.

Rationale for incorrect choices:

Respiratory rate 20/min: Although slightly decreased from admission, this is within a near-normal range for an 8-year-old and not immediately concerning. Continuous monitoring is appropriate, but it is not an urgent priority compared with perfusion and hemodynamic indicators.
Dressing on left hand shows small amount of moisture through gauze: Minor moisture in the dressing may reflect mild wound exudate, which requires routine monitoring and dressing changes. It does not indicate an immediate life-threatening risk.

Nursing Test Bank

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Correct Answer is A

Explanation

Rationale:

A. Serum potassium: Spironolactone is a potassium-sparing diuretic that can cause hyperkalemia. Monitoring serum potassium is essential to detect elevated levels early and prevent cardiac complications.

B. Platelet count: Spironolactone does not significantly affect platelet production or function, so routine monitoring of platelets is not indicated for this medication.

C. Urine ketones: Ketone monitoring is relevant for clients with uncontrolled diabetes or ketosis, but it is not related to spironolactone therapy.

D. Total bilirubin: Bilirubin levels are used to assess liver function, which is not directly affected by spironolactone in most clients, so routine monitoring is not necessary unless the client has underlying hepatic disease.

A. Place the head of the client's bed flat with the client's legs extended. B. Apply butterfly strips to approximate the wound edges. C. Apply pressure directly to the wound for 15 min. D. Place a sterile, saline-soaked dressing on the wound.

Correct Answer is D

Explanation

Rationale:

A. Place the head of the client's bed flat with the client's legs extended: Positioning flat may increase tension on the abdominal incision, potentially worsening the dehiscence. A low Fowler’s position with knees slightly bent is preferred to reduce strain on the wound.

B. Apply butterfly strips to approximate the wound edges: Forcing the wound edges together could trap bacteria inside and increase the risk of infection. Dehiscence requires moist protection, not forced closure at the bedside.

C. Apply pressure directly to the wound for 15 min: Direct pressure is appropriate for active bleeding, not for dehiscence. Applying pressure could damage tissues further and does not address the need to protect exposed structures.

D. Place a sterile, saline-soaked dressing on the wound: A moist sterile dressing protects the wound from contamination, prevents the tissues from drying, and reduces the risk of infection while awaiting further surgical evaluation.

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Body System	Findings
Integumentary	Skin feels cool to the touch. Capillary refill 3 seconds in left foot Dressing on left hand shows small amount of moisture through gauze.
Vital Signs	Blood pressure 102/50 mm Hg Temperature 35.8° C (96.4° F) Respiratory rate 20/min
Genitourinary	Output of 25 mL dark amber urine through catheter

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who is prescribed spironolactone. Which of the following laboratory values should the nurse monitor for this client?

Correct Answer is A

Explanation

A nurse caring for a postoperative client removes the client's dressing and notes an area of dehiscence. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

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A nurse is assessing a school-age child who has moderate dehydration due to diarrhea and vomiting. Which of the following manifestations should the nurse expect?

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