The nurse is caring for a child who is diagnosed with severe dehydration and is being treated with intravenous fluids. The nurse notes bilateral crackles on lung auscultation. Which actions will the nurse prioritize?

Call the healthcare provider.

Provide supplemental oxygen.

Stop the infusion.

Encourage oral intake.

Answer and Explanation

The Correct Answer is C

Choice A reason: Calling the healthcare provider is important, but the immediate priority is to stop the infusion to prevent further fluid overload, which is likely causing the bilateral crackles.

Choice B reason: Providing supplemental oxygen can be necessary if the child is showing signs of respiratory distress, but it is not the primary action to address the underlying issue of fluid overload.

Choice C reason: Stopping the infusion is the most critical action to prevent further fluid overload, which is causing the bilateral crackles. This immediate intervention can help prevent worsening pulmonary enema and respiratory complications.

Choice D reason: Encouraging oral intake is not appropriate in this scenario as the child is already receiving intravenous fluids for severe dehydration. Additionally, with signs of fluid overload, further fluid intake should be carefully managed.

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Correct Answer is D

Explanation

Choice A reason: Developing a plan of care with the child and family is important, but it does not explicitly address the need for cultural competence. This approach is cantered around collaboration rather than cultural sensitivity.

Choice B reason: Providing future-based care for culturally diverse children is vague and does not directly indicate an understanding or application of cultural competence in the current care situation.

Choice C reason: Treating all children the same regardless of their culture is contrary to the principles of culturally competent care. Culturally competent care involves recognizing and respecting the cultural differences that impact the child's health and tailoring the care to meet those unique needs.

Choice D reason: Assessing the child's culture and providing care based on the findings demonstrates an understanding and application of culturally competent care. This approach ensures that the care is respectful of and responsive to the cultural needs of the child and family.

A. Lethargy and hypotonia B. Elastic skin turgor C. Apical heart rate = 64 beats per minute D. Blood pressure = 100/54 mmHg E. Flat anterior fontanel

Correct Answer is ["A","C","D"]

Explanation

Choice A reason: Lethargy and hypotonia are critical findings in a child who was left in a closed car. These symptoms can indicate severe dehydration, heat stroke, or other serious conditions that require immediate medical attention.

Choice B reason: Elastic skin turgor generally indicates good hydration status and is not an immediate concern that needs to be reported urgently in this context.

Choice C reason: An apical heart rate of 64 beats per minute is significantly low for a 14-month-old child, indicating bradycardia, which can be a sign of severe heat stress or dehydration. This finding needs immediate reporting.

Choice D reason: A blood pressure of 100/54 mmHg is within the normal range for many paediatric patients, but in the context of being left in a hot car, it can suggest potential complications and should be monitored closely. However, it is not as critical as the heart rate and mental status findings.

Choice E reason: A flat anterior fontanel is a normal finding in infants and does not require urgent intervention in this context.

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The nurse is caring for a child who is diagnosed with severe dehydration and is being treated with intravenous fluids. The nurse notes bilateral crackles on lung auscultation. Which actions will the nurse prioritize?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The paediatric nurse is teaching the student nurse about culturally competent care. Which action will the student nurse identify as consistent with this type of care?

Correct Answer is D

Explanation

The emergency department nurse is assessing a 14-month-old child who was left inside a closed car for an hour. The outside temperature was 88 degrees Fahrenheit. Which assessment findings will the nurse report immediately to the health care provider? Select all that apply.

Correct Answer is ["A","C","D"]

Explanation

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