A nurse is reviewing the medical record of a toddler who has moderate dehydration. Which of the following findings should the nurse expect?
Decreased hematocrit
Increased respiratory rate
Decreased heart rate
Increased platelet count
The Correct Answer is B
A. Decreased hematocrit: Hematocrit usually increases in dehydration due to the concentration of red blood cells in a smaller volume of plasma.
B. Increased respiratory rate: Dehydration can lead to tachypnea (increased respiratory rate) as the body attempts to compensate for the decreased blood volume and maintain oxygen delivery.
C. Decreased heart rate: Dehydration typically causes tachycardia (increased heart rate) as the body tries to maintain adequate blood circulation and pressure.
D. Increased platelet count: Dehydration does not typically affect platelet count significantly, though it may concentrate blood components, including platelets, making them appear elevated on a lab test.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. "Give her acetaminophen, not aspirin." This is the appropriate response. Acetaminophen is commonly recommended for treating fever in children as it is safer and does not carry the risk of Reye's syndrome, a rare but serious condition associated with aspirin use in children and adolescents, particularly when they have viral infections. This response provides a safe alternative and addresses the immediate concern of fever treatment.
B. "You'll have to call your physician." While consulting a physician is generally good advice, this response does not provide immediate guidance or address the potential risks of giving aspirin to a toddler. It leaves the parent without immediate and necessary information to prevent harm.
C. "Follow the directions on the aspirin bottle for her age and weight." This response is inappropriate and potentially harmful. Aspirin should not be given to children, especially without a physician's guidance, due to the risk of Reye's syndrome. Following dosage directions on an aspirin bottle is unsafe for a toddler, as aspirin is not recommended for children in this age group for fever treatment.
D. "Give her no more than three baby aspirin every 4 hours." This is incorrect and dangerous advice. Giving any amount of aspirin to a toddler is not recommended because of the risk of Reye's syndrome. Suggesting a specific dosage implies that it's safe to give aspirin to a child, which it is not in this context.
Correct Answer is C
Explanation
A. Remove the window and view the incision. Inspecting the incision through the cast window is important for monitoring for signs of infection or complications, but it is not the first priority. Ensuring the extremity has adequate circulation and function is critical initially.
B. Medicate the client for pain. Pain management is essential, especially postoperatively, but assessing the integrity and function of the affected extremity takes precedence to ensure there are no immediate complications like compromised circulation or nerve damage.
C. Perform neurovascular checks of the affected extremity. Performing neurovascular checks is the highest priority to ensure that circulation, sensation, and movement are intact. This helps identify any immediate issues with the cast or complications from surgery that could jeopardize the limb’s health.
D. Turn the client so the cast will dry on all sides. Ensuring the cast dries properly is important to maintain its integrity and effectiveness, but this action is secondary to assessing neurovascular status to prevent serious complications.
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