A school-age client diagnosed with autism is admitted to the hospital because of recent vomiting and diarrhea. Which intervention by the nurse is most appropriate upon admission?

Take the child on a tour of the whole unit to familiarize with the surroundings.

Admit the child to a four-bed room to allow interaction with peers.

Orient the child to the hospital room.

Take the child to the playroom immediately to participate in the arts and crafts activity.

Answer and Explanation

The Correct Answer is C

Choice A reason: Taking the child on a tour might be overwhelming and increase anxiety due to the new environment and sensory overload.

Choice B reason: Placing the child in a four-bed room could lead to overstimulation and discomfort due to the presence of multiple unfamiliar people.

Choice C reason: Orienting the child to the hospital room provides a safe and controlled environment, allowing for gradual adjustment to the new setting.

Choice D reason: Immediately taking the child to the playroom for arts and crafts might be too stimulating and could exacerbate stress rather than ease the transition.

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Correct Answer is C

Explanation

Choice A reason: Lifting and clearing drainage from the chest tube is not necessary unless there is a blockage, which is not indicated by the water level changes.
Choice B reason: Inspecting the tube insertion site for leaking is important but not related to the observation of water level changes in the water-seal chamber.
Choice C reason: This is the correct choice. The water level rising during inspiration and falling during expiration is a normal finding that indicates the chest tube is functioning properly.
Choice D reason: Auscultating lungs for unequal breath sounds is part of the assessment but does not address the observed water level changes in the water-seal chamber.

A. Ensure IV fluid replacement is a hypertonic solution. B. Assess for cardiac arrest related to high potassium levels. C. Monitor the child's vital signs for hypertension. D. Administer intravenous NPH insulin in high doses.

Correct Answer is D

Explanation

Choice A reason: IV fluid replacement in DKA is typically isotonic, not hypertonic, to avoid rapid changes in osmolality.
Choice B reason: While monitoring for cardiac arrest is important, it is not the primary intervention; DKA often presents with low potassium levels that rise with treatment.
Choice C reason: Monitoring for hypertension is important, but the primary concern in DKA is managing the acidosis and hyperglycemia.
Choice D reason: This is the correct choice. Administering insulin is a key component of treating DKA to reduce blood glucose levels and reverse ketosis. NPH insulin is not typically used in the initial management of DKA; rapid-acting insulin is preferred. However, if NPH is mentioned in the context provided, it would be important to clarify the treatment protocol.

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A school-age client diagnosed with autism is admitted to the hospital because of recent vomiting and diarrhea. Which intervention by the nurse is most appropriate upon admission?

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Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

Which of the following is of primary importance for a child who is admitted to the PICU for DKA (diabetic ketoacidosis)?

Correct Answer is D

Explanation

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