The nurse is caring for a 2-year-old patient. Which observation requires immediate action by the nurse?

The identification band has fallen off the patient's leg.

The IV fluid is 48 hours old.

The crib rails are halfway up.

The bed linen is damp.

Answer and Explanation

The Correct Answer is B

Choice A rationale:

The identification band falling off the patient's leg is a documentation concern and doesn't require immediate action unless the patient is at risk of wandering or abduction.

Choice B rationale:

IV fluids should be changed every 24 hours to prevent bacterial growth and infection. Using fluids that are 48 hours old increases the risk of introducing infection to the patient.

Choice C rationale:

The crib rails being halfway up is not an immediate concern unless the child is at risk of falling or climbing out of the crib.

Choice D rationale:

Damp bed linen can be addressed during the next bedding change. It may not require immediate action unless the patient's skin integrity is at risk.

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Correct Answer is C

Explanation

Choice A rationale:

Fever and hypertension are not typical findings in moderate dehydration. Dehydration often leads to hypotension rather than hypertension, and fever is not a direct consequence of dehydration.

Choice B rationale:

Increased specific gravity can be a sign of dehydration, but it is not as specific or sensitive as tachypnea (rapid breathing) and tachycardia (elevated heart rate), which occur due to the body's compensatory mechanisms in response to dehydration.

Choice C rationale:

Tachypnea and tachycardia are key indicators of moderate dehydration in infants. The body tries to maintain perfusion by increasing the heart rate and respiratory rate. These signs are more reliable indicators of dehydration than specific gravity or fever.

Choice D rationale:

Bulging posterior fontanel is not a typical finding in dehydration. A sunken fontanel might be more indicative of dehydration, as fluid shifts from the intracellular to the extracellular space.

A. Have the child choose a place in his room for the dog where he can see it but it is beyond his reach. B. Tell the mother that it is all right to keep the dog with him. C. Suggest to the mother that she tell the child that she will bring the dog back after taking it home to wash it. D. Suggest to the mother that she choose a replacement from the stuffed animals in the playroom.

Correct Answer is A

Explanation

Choice A rationale:

Allowing the child to have the soiled stuffed dog within sight but out of reach respects his attachment to the comfort object while maintaining hygiene standards of the hospital environment. The child's emotional well-being is crucial, and separation from a beloved item during a hospital stay can be distressing. Placing the dog in view but inaccessible helps strike a balance between comfort and infection control.

Choice B rationale:

While the mother's desire to keep the dog with the child is understandable, infection control is a concern in a hospital setting. Allowing the soiled object to remain in close proximity could compromise the child's health.

Choice C rationale:

Suggesting that the mother take the dog home to wash it and bring it back later might cause unnecessary distress for the child, who may worry about being separated from the comfort object for an extended period.

Choice D rationale:

Choosing a replacement from the playroom's stuffed animals could be unsettling for the child, as his attachment is to his specific dog. The familiarity of his own toy is likely to provide more comfort during the hospitalization. .

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The nurse is caring for a 2-year-old patient. Which observation requires immediate action by the nurse?

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Naxlex Comprehensive Predictor Exams

When assessing an infant with moderate dehydration, a nurse would expect which assessment findings?

Correct Answer is C

Explanation

A 4-year-old patient with cystic fibrosis is hospitalized with an acute pulmonary exacerbation. When the patient is admitted, he is clutching a soiled, tattered, stuffed dog. His mother says, "He insisted on bringing the dog with him. It really is filthy.". Which nursing action is most appropriate?

Correct Answer is A

Explanation

The nurse is caring for a 2-year-old patient. Which observation requires immediate action by the nurse?

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