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The client is a 12-year-old male who sustained a gunshot wound to his abdomen. He had a surgical repair of a perforated small intestine 4 days ago. The client is 112.4 Ib. (51 kg). He has a nasogastric tube, a left femoral central line for fluids, and a right hand peripheral intravenous line.

Review H and P, laboratory results, flow sheet, and orders.

The nurse receives the report from the lab and documents the intake and output for 1600.

Based on the client's information at 1600, what symptoms should the nurse look for? Select all that apply.

Edema

Irritability

Fatigue

Dry skin

Intense thirst

Muscle weakness

Hypertension

Answer and Explanation

Correct Answer : A,D,E,F

A. Edema can be a symptom to watch for, as it may indicate fluid retention or imbalance, especially in a client who has received intravenous fluids.

D. Dry skin may be a symptom to observe, as it could suggest dehydration or fluid imbalances.

E. Intense thirst is a symptom to be alert for, as it may be an indication of dehydration or an electrolyte imbalance.

F. Muscle weakness is a potential symptom to monitor for, as it could be related to electrolyte imbalances or other complications following surgery and injury.

B, C, and G are not the primary symptoms to expect based on the client's information and history, but they should still be monitored as part of routine assessment. Irritability and fatigue can be nonspecific symptoms that may occur in various clinical situations. Hypertension may or may not be a symptom, and it is essential to assess the client's blood pressure in the context of their overall condition.

The client's history and the presence of medical devices and surgical intervention indicate the need for close monitoring of fluid balance and electrolyte status.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

A. Giving the injection in the arm, one to 2 inches below the acromion process, is a technique typically used for adults or older children. It may not be suitable for a toddler of this age.

B. Using a needle length of 1/2 inch is not appropriate for intramuscular injections in a toddler. It may not reach the muscle tissue, leading to ineffective administration.

C. Dividing the gluteal area into quarters and giving the injection into the upper outer quadrant is a technique typically used for older children and adults, not for toddlers. It's also important to avoid intramuscular injections in the gluteal area for young children due to the risk of injury to the sciatic nerve.

D. Administering the injection into the middle of the lateral aspect of the thigh is the preferred technique for intramuscular injections in toddlers. The thigh muscles are a safe and effective site for IM injections in this age group. The middle of the lateral aspect of the thigh is commonly chosen because it provides a sufficient muscle mass for proper absorption of the medication and minimizes the risk of injury to nerves or vessels. This technique is recommended for toddlers who are walking and have developed sufficient muscle mass in the thigh area.

A. Electrocardiogram: Tall T wave and widened QRS complex B. Blood pressure: 126/76 mm Hg C. Basilar crackles D. Urine output: 20 mL in the last hour E. Respirations: 26 breaths/minute F. Heart rate: 72 beats/minute G. Oxygen saturation 98% on room air H. A normal body temperature (98.9°F or 37.1°C orally).

Correct Answer is ["B","F","G","H"]

Explanation

A. An electrocardiogram with a tall T wave and widened QRS complex may indicate electrolyte imbalances or cardiac issues, which are not indicative of stabilization.

C. Basilar crackles can be a sign of pulmonary or cardiac issues and are not indicative of stabilization.

D. A urine output of 20 mL in the last hour may suggest reduced kidney function or hydration status and is not indicative of stabilization.

E. A respiratory rate of 26 breaths/minute may indicate respiratory distress and is not indicative of stabilization.

The assessment findings that suggest stabilization include:

A blood pressure within the normal range (126/76 mm Hg).

A heart rate within the normal range (72 beats/minute).

Oxygen saturation of 98% on room air, indicating adequate oxygenation.

A normal body temperature (98.9°F or 37.1°C orally).

These vital signs and clinical parameters are within normal ranges, suggesting that the client's condition is stable at this time.

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Naxlex Comprehensive Predictor Exams

The nurse is giving an intramuscular injection of an antibiotic to a 16-month-old toddler with pneumonia. The toddler does not have any known allergies and has been walking without assistance for one month. Which technique should the nurse select for administration?

Correct Answer is D

Explanation

Exhibits Two days later, the nurse completes an assessment of the client. Which assessment findings indicate that the client has stabilized? Select all that apply.

Correct Answer is ["B","F","G","H"]

Explanation

The parents of a 14-month-old child who is hospitalized due to febrile seizures tell the nurse that they fear their child will have lifelong seizures. Which information should the nurse convey to these parents?

A six-year-old girl is being admitted to the hospital for repair of an umbilical hernia. Which information, collected by the admitting nurse, is particularly helpful in planning care for this child?

A male adolescent arrives at the clinic and reports intense pain in the testicular area that occurred during football practice at high school. The nurse observes the scrotum and identifies significant erythema and swelling. Which action should the nurse take?

The nurse is providing education to parents about preventing otitis media recurrence in their infant. Which instruction should the nurse include?

During her sports physical examination, a 15-year-old female requests oral contraceptives. She explains that she is sexually active and does not want her parents to know. Which action should the nurse take?

The mother of an 11-year-old boy who has juvenile idiopathic arthritis tells the nurse, "I really don't want my son to become dependent on pain medication, so I only allow him to take it when he is really hurting." Which information is most important for the nurse to provide this mother?

The nurse is caring for an infant with unilateral clubfoot. Which information should the nurse include in parent education about long-term outcomes?