A nurse is caring for a 7-year-old child who has severe dehydration. Which of the following findings should the nurse expect?
Blood pressure 94/68 mm Hg
Urinary output 30 mL/hr
Respiratory rate 24/min
Heart rate 152/min
The Correct Answer is D
A. A blood pressure of 94/68 mm Hg is within the normal range for a 7-year-old child and may indicate compensated dehydration rather than severe dehydration.
B. A urinary output of 30 mL/hr is insufficient and may indicate dehydration, but it does not specifically indicate severe dehydration.
C. A respiratory rate of 24/min is within the normal range for a 7-year-old child and is not specifically indicative of severe dehydration.
D. Tachycardia (heart rate >100 beats per minute) is a common finding in severe dehydration as the body attempts to compensate for decreased blood volume by increasing heart rate.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Providing a flexible activity schedule allows the client to engage in activities that match their energy level and interests, promoting a sense of control and reducing agitation during acute
mania.
B. High-calorie nutritional supplements are not typically indicated solely based on the diagnosis of acute mania. Nutritional needs should be assessed, but providing high-calorie supplements
may not address the underlying issues associated with mania.
C. Allowing the client to eat meals alone in her room may not be safe or therapeutic during acute mania, as supervision during meals can ensure adequate nutrition and prevent potential harm or
inappropriate behaviors.
D. While promoting independence is important, allowing the client to choose her clothes independently may not be appropriate during acute mania, as it could result in wearing
inappropriate attire or exacerbate impulsivity.
Correct Answer is D
Explanation
A. Routine activities such as daily baths are not typically pertinent information to include in a change-of-shift report unless they have a significant impact on the client's condition or care.
B. While vomiting after surgery may be noteworthy, the timing and amount of emesis
immediately after surgery may not be relevant to the client's current condition, especially if it was an isolated incident.
C. Flushing the IV with normal saline is a routine nursing intervention and may not be necessary to report unless there were specific concerns or complications related to the IV.
D. Pain relief is an important aspect of postoperative care and should be included in the report to ensure continuity of care and appropriate pain management for the client.
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