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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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Free Nursing Study Resources

Correct Answer is C

Explanation

A. "Polyuria can be caused by using antidepressants.": Antidepressants are more commonly associated with urinary retention or hesitancy rather than polyuria, so this statement reflects a misunderstanding of the typical causes.

B. "Polyuria can be caused by enlargement of the prostate gland.": Prostate enlargement usually causes urinary retention, difficulty initiating urination, or nocturia, rather than excessive urine output.

C. "Polyuria can be caused by drinking too much fluid.": Excessive fluid intake increases urine production, which is a common and direct cause of polyuria. This reflects an accurate understanding of one of the typical mechanisms leading to increased urine output.

D. "Polyuria can be caused by trauma to the lower urinary tract.": Trauma is more likely to result in hematuria, pain, or retention, not necessarily polyuria. This statement does not accurately reflect a common cause of excessive urination.

A. A client who has epidural analgesia and weakness in the lower extremities B. A client who has diabetes mellitus and an HbA1c of 7.2% (less than 79%). C. A client who has sinus arrhythmia and is receiving cardiac monitoring. D. A client who has a hip fracture and a new onset of tachypnea.

Correct Answer is D

Explanation

A. A client who has epidural analgesia and weakness in the lower extremities: Lower extremity weakness can be a side effect of epidural analgesia. While it requires monitoring, it is typically not immediately life-threatening unless accompanied by other neurological changes.

B. A client who has diabetes mellitus and an HbA1c of 7.2%: An HbA1c of 7.2% indicates slightly above-target blood glucose control. This is a chronic management concern and does not require immediate intervention.

C. A client who has sinus arrhythmia and is receiving cardiac monitoring: Sinus arrhythmia is often a benign, expected finding, particularly in children or young adults. Continuous monitoring is appropriate, but it is not an emergent concern.

D. A client who has a hip fracture and a new onset of tachypnea: New-onset tachypnea in a client with a hip fracture can indicate a serious complication such as pulmonary embolism or fat embolism syndrome. This requires immediate assessment and intervention.

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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 providing education about the common causes of polyuria to a client who has a urinary alteration. Which of the following client statements indicates an understanding of the teaching?

Correct Answer is C

Explanation

Which of the following clients should be considered a priority for immediate assessment and intervention?

Correct Answer is D

Explanation

A nurse is caring for a client in the emergency department. Exhibits Which of the following interventions should the nurse include in the plan of care? Select all that apply.

A nurse is caring for a client who received a transfusion of 250 mL of packed RBCs. The nurse should identify that which of the following findings indicates the client is responding positively to the transfusion?

A nurse is administering furosemide IV bolus to a client who has fluid volume excess. The nurse should recognize which of the following findings as an indication that the medication has been effective?

A nurse manager is conducting a performance appraisal of a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates effective time management?

The nurse reviews the entries in the medical record. Exhibits The nurse is preparing the client for a blood transfusion, which of the following actions should the nurse take? Select all that apply.

A nurse reviews the provider prescriptions and reassesses the client. Exhibits The nurse is continuing to care for the client. Which of the following actions should the nurse take? Select all that apply.

A nurse is caring for a client who is 4 hr postoperative following a total knee arthroplasty. The client reports a pain level of 3 on a scale from 0 to 10. Which of the following nonpharmacological pain management therapies should the nurse recommend?

A nurse is preparing to administer eye drops to a school-age child. Identify the actions the nurse should take. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)