A nurse is assessing a toddler who has gastroenteritis and is exhibiting manifestations of dehydration. Which of the following findings should the nurse address first?
Hypotension
Tachypnea
Нурегругехіа
Skin breakdown
The Correct Answer is A
A. Hypotension is the most critical finding in dehydration, as it indicates severe fluid loss and can lead to shock. Immediate intervention is required to address the circulatory compromise.
B. Tachypnea is a compensatory response to dehydration and may not require as immediate attention as hypotension.
C. Hyperpyrexia (high fever) can occur in gastroenteritis but is less urgent compared to hypotension.
D. Skin breakdown is a concern in dehydrated patients, but hypotension poses a more immediate threat to life.
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Related Questions
Correct Answer is B
Explanation
A. A pacifier should not be offered after cleft lip surgery, as it can put pressure on the surgical site and affect healing.
B. Rocking the infant can be a soothing and comforting action to help the infant recover from surgery. It provides emotional comfort and promotes bonding with the parents.
C. Ibuprofen is generally not recommended for infants under 6 months of age unless prescribed by the provider. Appropriate pain management should be used based on the infant's age and condition.
D. Positioning the infant on her abdomen is not appropriate after cleft lip surgery, as this could place pressure on the surgical area. The infant should be positioned on her back or side to avoid stress on the repair site.
Correct Answer is ["A","C","E"]
Explanation
2100: Child brought into the emergency department by their guardians. The child has Acute Lymphoblastic Leukemia (ALL) and is currently in the induction phase of treatment for standard risk. The child received chemotherapy with vincristine 8 days ago and is taking daily oral steroids. Child is alert, crying, and clinging to guardian. Guardians report the child has not had a bowel movement for 5 days.
2100:
Pulse 120/min
Respiratory rate 25/min
Temperature 38.8° C (101.9° F) tympanic
SaO2 96% on room air
2120: Child now asleep in guardian's arms. Respirations unlabored, heart rate regular. Child has a double-lumen central line catheter in the left chest wall. Insertion site is erythematous with a scant amount of purulent drainage.
Rationale:
Temperature of 38.8°C (101.9°F) tympanic: Fever in a child with leukemia is concerning as it may indicate an infection, especially since the child is immunocompromised due to chemotherapy. This needs immediate follow-up and potentially blood cultures to determine the source of infection.
Erythema and purulent drainage at central line insertion site: Purulent drainage and erythema at the central line insertion site suggest a possible infection, such as a catheter-associated bloodstream infection. This requires prompt follow-up, possibly including antibiotic therapy and further investigations to prevent sepsis.
Child has not had a bowel movement for 5 days: Constipation is a common side effect of chemotherapy and oral steroids, but a delay in bowel movements could indicate bowel obstruction or other gastrointestinal issues. This needs to be addressed, and the child may require laxatives or further investigation.
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