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. Report sudden, persistent headaches. – Correct. Persistent headaches may indicate a stroke, a severe complication of sickle cell anemia due to vaso-occlusion.

B. Restrict fluid intake during times of stress. – Incorrect. Hydration is crucial to prevent sickling of red blood cells. Fluids should be increased, not restricted.

C. Apply cold compresses to painful areas. – Incorrect. Cold can cause vasoconstriction and worsen sickling. Warm compresses are recommended instead.

D. Avoid meningococcal immunizations. – Incorrect. Children with sickle cell anemia are at increased risk for infections and should receive all recommended vaccinations, including the meningococcal vaccine.

A. Discuss a long-term care referral for the client with the provider. B. Review assisted living accommodations with the client. C. Suggest that the client attend adult day care three times per week. D. Instruct the client about the use of telehealth services.

Correct Answer is D

Explanation

A. A referral to long-term care is premature since the client lives independently and may not require institutionalized care.

B. Assisted living accommodations are not necessary unless the client struggles with self-care or safety concerns.

C. Adult day care is beneficial for socialization but does not address the primary issue of diabetes management in a rural setting.

D. Telehealth services allow clients in rural areas to consult with healthcare providers remotely, improving access to care, medication management, and education on diabetes self-care.

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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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