Nokea
A 9-month-old is admitted because of dehydration. How should the nurse go about accurately monitoring fluid intake and output? Select all that apply.
- A. Weighing and recording all wet diapers.
- B. Obtaining a urine specific gravity measure.
- C. Obtaining an accurate daily weight.
- D. Restricting fluids prior to weighing the child.
- E. Obtaining an accurate stool count.
Correct Answer: A,C,E
Rationale: Weighing diapers, daily weights, and stool counts accurately track fluid balance.
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A school-age child who has received burns over 60% of his body is to receive 2,000 mL of I.V. fluid over the next 8 hours. At what rate (in milliliters per hour) should the nurse set the infusion pump?
Correct Answer: 250
Rationale: Dividing 2,000 mL by 8 hours yields 250 mL/hour. This ensures fluid resuscitation meets burn protocol (e.g., Parkland formula) to maintain hemodynamic stability.
A nurse working in the nursery identifies a goal for a mother of a newborn to demonstrate positive attachment behaviors upon discharge. Which intervention would be least effective in accomplishing this goal?
- A. Provide opportunities for the mother to hold and examine the newborn.
- B. Engage the mother in the newborn's care.
- C. Create an environment that fosters privacy for the mother and newborn.
- D. Identify strategies to prevent difficulties in parenting.
Correct Answer: D
Rationale: Preventing parenting difficulties is less directly related to fostering immediate attachment.
Laboratory findings indicate that a child with leukemia is also anemic. The nurse interprets this finding as most likely resulting from which of the following?
- A. Inadequate dietary folic acid intake.
- B. Decreased red blood cell production.
- C. Increased destruction of red blood cells by lymphocytes.
- D. Progressive replacement of bone marrow with scar tissue.
Correct Answer: B
Rationale: Leukemia crowds out bone marrow, reducing red blood cell production, causing anemia. Other causes are less likely.
The nurse judges that the mother understands the diet restrictions for her child with chronic renal failure who is receiving peritoneal dialysis when she reports providing a diet involving which of the following?
- A. Sodium and water restrictions.
- B. High protein and carbohydrates.
- C. High potassium and iron.
- D. Protein and phosphorus restrictions.
Correct Answer: A
Rationale: Dietary restrictions help manage symptoms.
The nurse discusses the eating habits of school-age children with their parents, explaining that these habits are most influenced by:
- A. Food preferences of their peers.
- B. Smell and appearance of foods offered.
- C. Examples provided by parents at mealtimes.
- D. Parental encouragement to eat nutritious foods.
Correct Answer: C
Rationale: Parental modeling during meals strongly influences children's eating habits.