Exhibits
A nurse is caring for a school-age child who is dehydrated. Which of the following findings should the nurse report to the provider? (Click on the exhibit tabs for additional information about the client. There are three tabs that contain separate categories of data.)
Respiratory rate
Heart rate
Capillary refill
Urine output
The Correct Answer is C
A. Respiratory rate: A respiratory rate of 22/min is within the normal range for a school-age child (18–30/min). This does not suggest acute distress or worsening dehydration, so it does not require reporting.
B. Heart rate: A heart rate of 96/min is normal for a school-age child (75–118/min). It does not indicate tachycardia or hypovolemic compromise and therefore is not concerning.
C. Capillary refill: A prolonged capillary refill time is a key indicator of poor peripheral perfusion, which can be a sign of moderate to severe dehydration and hypovolemia. This finding suggests that the child is not adequately compensating for their fluid loss.
D. Urine output: A urine output of 100 mL in 4 hours is within the expected range for a child of this weight. The normal urine output for a child is approximately 1 mL/kg/hr. For this child (22.7 kg), the expected output would be 22.7 mL/hr. Over 4 hours, this would be 90.8 mL.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Take the child's temperature every 10 min after administering acetaminophen: Monitoring the temperature this frequently is unnecessary and can cause anxiety for both the child and parent. Temperatures should be reassessed every few hours to evaluate medication effectiveness.
B. Wake the child every 4 hr during the night to drink 118.3 mL (4 oz) of apple juice: Rest is crucial for recovery, and children should not be routinely awakened at night for fluids unless directed by a provider. Adequate hydration should be encouraged during waking hours instead.
C. Apply a light blanket if the child begins to shiver: Shivering increases metabolic demand and body temperature. Covering the child lightly during chills helps reduce discomfort without causing overheating, making this an appropriate home care measure.
D. Place ice packs on the child's armpits and groin: Using ice packs can cause vasoconstriction and discomfort without effectively reducing fever. Safer methods include ensuring comfort with lightweight clothing, hydration, and antipyretics as prescribed.
Correct Answer is A
Explanation
A. Pale, oily stools: Celiac disease causes malabsorption due to an immune response to gluten, leading to steatorrhea. The stools are typically pale, foul-smelling, and oily because of impaired fat absorption.
B. Redcurrant, jelly-like stools: This type of stool is characteristic of intussusception, a condition where part of the intestine telescopes into itself, causing bleeding and mucus, not celiac disease.
C. Increased hemoglobin level: Children with celiac disease often experience iron deficiency anemia due to malabsorption, which lowers hemoglobin levels. An increase in hemoglobin would not be expected.
D. Hematemesis: Vomiting blood is not a typical finding in celiac disease. It is more commonly associated with upper gastrointestinal bleeding from ulcers or esophageal varices.
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