A nurse is caring for a 3-year-old toddler who has dehydration. Which of the following findings should the nurse report to the provider?

Heart rate 148/min

Potassium 3.9 mEq/L

Respiratory rate 22/min

Sodium 142 mEq/L

Answer and Explanation

The Correct Answer is A

A. Heart rate 148/min – Correct. A heart rate of 148/min in a 3-year-old is elevated (tachycardia) and may indicate worsening dehydration or shock.

B. Potassium 3.9 mEq/L – Incorrect. This potassium level is within the normal range (3.5–5.0 mEq/L).

C. Respiratory rate 22/min – Incorrect. This is within the expected range for a 3-year-old.

D. Sodium 142 mEq/L – Incorrect. This sodium level is within the normal range (135–145 mEq/L).

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Correct Answer is A

Explanation

A. This is the correct answer. Older adults are at risk for fluid overload, so infusing blood over 4-5 hours (instead of the usual 2-4 hours) is safer.

B. Blood products must be infused with 0.9% sodium chloride (normal saline) only. Dextrose-containing solutions cause hemolysis.

C. A 20-gauge catheter is acceptable, but a larger bore (18-gauge) is preferred for faster infusion.

D. Vital signs should be monitored before the transfusion, 15 minutes after starting, then every 30-60 minutes, and at completion.

A. A client who had a right hemisphere stroke B. A client who had dialysis and is using an arteriovenous shunt in the left lower forearm C. A client who had blood drawn from the right antecubital area 1 hr ago D. A client who has a right peripherally inserted central catheter

Correct Answer is D

Explanation

A. A client who had a right hemisphere stroke – While a stroke may cause weakness on one side, BP measurements can still be taken unless there are additional contraindications like lymphedema or a fistula.

B. A client who had dialysis and is using an arteriovenous shunt in the left lower forearm – BP should never be taken on the arm with an AV shunt, but this does not mean the right arm is unavailable.

C. A client who had blood drawn from the right antecubital area 1 hr ago – Blood draws do not typically affect BP measurements significantly unless there is excessive bruising or infiltration.

D. A client who has a right peripherally inserted central catheter (PICC) – Correct. Blood pressure cuffs can cause compression on the PICC line, leading to catheter occlusion, displacement, or thrombosis. The nurse should instruct the AP to use the opposite arm.

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A nurse is caring for a 3-year-old toddler who has dehydration. Which of the following findings should the nurse report to the provider?

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