The nurse is to record the intake and output of a 2-year-old patient. The patient is not toilet trained. Which measure would be most appropriate to include in the patient's plan of care?

Obtaining an order to have an indwelling urinary catheter inserted.

Weighing the patient's wet diapers prior to discarding them.

Sitting the patient on the bedpan at least every two hours.

Applying a pediatric urine collection device over the patient's urinary meatus.

Answer and Explanation

The Correct Answer is B

Weighing the patient's wet diapers prior to discarding them.

Choice A rationale:

Inserting an indwelling urinary catheter is invasive and not appropriate for a non-toilet-trained 2-year-old unless medically necessary.

Choice B rationale:

Weighing wet diapers is the most accurate way to measure urine output in a young child who isn't toilet trained. This method provides essential information for assessing hydration and kidney function.

Choice C rationale:

Sitting the patient on the bedpan every two hours is suitable for older children but may not be effective or tolerable for a 2-year-old.

Choice D rationale:

Applying a pediatric urine collection device is an option, but it might not be as accurate as weighing wet diapers and may cause discomfort for the child.

Nursing Test Bank

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Correct Answer is A

Explanation

Choice A rationale:

An increasing pulse rate suggests that the patient's condition is worsening. Tachycardia can indicate increased work of breathing and decreased oxygenation, which are concerning signs in laryngotracheobronchitis.

Choice B rationale:

Mouth breathing is a common response to airway obstruction, such as in laryngotracheobronchitis. While it indicates respiratory distress, it doesn't specifically suggest a worsening of the condition.

Choice C rationale:

An increase in nasal discharge might be seen with the common cold or other upper respiratory infections but is not a specific indicator of worsening laryngotracheobronchitis.

Choice D rationale:

A hoarse cry is a characteristic symptom of laryngotracheobronchitis due to inflammation of the airway. However, it is a common initial symptom and may not directly correlate with worsening of the condition.

A. Monitoring the stool consistency. B. Checking the pupillary reflex response. C. Listening to breath sounds. D. Auscultating the apical pulse rate.

Correct Answer is A

Explanation

Choice A rationale:

Monitoring the stool consistency is a crucial nursing action to assess the effectiveness of pancreatic enzyme replacement therapy. Patients with pancreatic insufficiency, such as those with cystic fibrosis, may have difficulty digesting fats properly. Improved stool consistency, specifically a reduction in greasy and foul-smelling stools, indicates that the pancreatic enzymes are aiding in fat digestion.

Choice B rationale:

Pupillary reflex response assessment is unrelated to pancreatic enzyme replacement therapy. It is more commonly performed to assess neurological status or the effects of medications affecting the autonomic nervous system.

Choice C rationale:

Listening to breath sounds is important for assessing respiratory status, but it does not directly reflect the effectiveness of pancreatic enzyme replacement therapy.

Choice D rationale:

Auscultating the apical pulse rate is a general assessment of cardiovascular function and does not provide information about the effectiveness of pancreatic enzyme replacement therapy.

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The nurse is to record the intake and output of a 2-year-old patient. The patient is not toilet trained. Which measure would be most appropriate to include in the patient's plan of care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A patient is admitted from the emergency room with laryngotracheobronchitis. The patient has a brassy cough, stridor, and substernal retractions. The child is receiving an intravenous infusion and is placed in a mist tent. Which observation would indicate a worsening of the patient's condition?

Correct Answer is A

Explanation

A nurse is caring for a pediatric client who is receiving pancreatic enzyme replacement therapy. Which nursing action measures the effectiveness of the therapy?

Correct Answer is A

Explanation

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