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This is an 11-month-old male with a 2-day history of fussiness, increased nasal secretions, and cough. The baby is 24.3 lb. (11 kg). He was born at 34 weeks gestation and spent several weeks in the neonatal intensive care unit for poor feeding.

He is currently up to date on vaccinations and is meeting appropriate developmental milestones. The parents deny that he takes any medications at home.

Review H and P and flow sheet.

Select which assessment findings indicate that the baby has an increased fluid requirement. Select all that apply.

Temperature 103 °F (39.4 °C)

Blood pressure 89/51 mmHg

Respiratory rate 55 breaths/min

Copious, clear secretions from both nostrils

Oxygen saturation 95%

Wet diaper with 12 mL of urine

Heart rate 159 bpm

Answer and Explanation

Correct Answer : A,C,D,E

Fever increases fluid loss through perspiration.

Increased respiratory rate can lead to increased fluid loss through evaporation. Increased nasal secretions can result in fluid loss.

High oxygen flow can cause drying of the mucous membranes and increase fluid requirements.

The following findings do not necessarily indicate increased fluid requirements: Blood pressure alone does not indicate increased fluid requirements.

Oxygen saturation within the normal range does not indicate increased fluid requirements.

Although urine output is important to assess hydration status, 12 mL of urine may not necessarily indicate increased fluid requirements.

Heart rate alone does not indicate increased fluid requirements.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Correct Answer is ["A","B","C","D","E"]

Explanation

It is important to assess the child's vital signs, including oxygen saturation (SaO2), to ensure their stability and identify any signs of respiratory distress or other abnormalities that may impact medication administration.

Prior to administering any medication, it is crucial to verify if the child has any known allergies to medications. This information is essential for ensuring the safety of the child and preventing any potential allergic reactions.

Before administering pain medication, the nurse must verify that the prescribed dosage is appropriate for the child's age, weight, and condition. Ensuring the correct dosage helps prevent medication errors and potential adverse effects.

It is important to use a validated pain assessment tool that is appropriate for the child's age and cognitive abilities. This allows for a comprehensive and accurate assessment of the child's pain level, helping guide appropriate pain management interventions.

Considering the child has cognitive and speech delays, the input from the parent regarding the child's pain is valuable. The nurse should assess and consider the parent's report of the child's pain in conjunction with other assessment findings to ensure effective pain management.

Subjective pain assessment is mentioned as a finding but may not require immediate action, as it needs to be combined with other assessment data for a comprehensive evaluation.

A. Diapering will be provided since hospitalization is stressful to preschoolers. B. A retraining program will need to be initiated when the child returns home. C. A potty chair should be brought from home so he can maintain his toileting skills. D. Children usually resume their toileting behaviors when they leave the hospital.

Correct Answer is D

Explanation

The correct answer is choiced. Children usually resume their toileting behaviors when they leave the hospital.

Choice A rationale:

While it is true that hospitalization can be stressful for preschoolers, providing diapers may not be necessary. Regression in toileting is often temporary and related to the stress of the hospital environment.

Choice B rationale:

Initiating a retraining program immediately after returning home may not be necessary. Most children will naturally resume their previous toileting behaviors once they are back in a familiar and less stressful environment.

Choice C rationale:

Bringing a potty chair from home can be helpful in some cases, but it is not always practical or necessary. The child is likely to resume normal toileting behaviors once they are back in their usual environment.

Choice D rationale:

This is the correct answer because children often regress in their toileting behaviors due to the stress and unfamiliarity of the hospital environment.Once they return home, they typically resume their previous toileting habits.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["A","B","C","D","E"]

Explanation

A 3-year-old boy was successfully toilet trained prior to his admission to the hospital for injuries sustained from a fall. His parents are very concerned that the child has regressed in his toileting behaviors. Which information should the nurse provide to the parents?

Correct Answer is D

Explanation

The nurse observes a client prepare a meal in the kitchen of a rehabilitation facility prior to discharge. Which behavior(s) indicate the client understands how to maintain balance safely? (Select all that apply.)

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