Nokea
A dehydrated child who weighs 10 kg
A dehydrated child has intravenous aid therapy ordered. The child weighs 10 kg. Physician ordered Lactated Ringer's solution 40 ml/kg over 4 hours How many miles per hour will this child receive?
- A. 300ml/hour
- B. 100 mL/hour
- C. 50mL/hour
- D. 200 ml/hour
Correct Answer: B
Rationale: The correct answer is B: 100 mL/hour. To calculate the IV rate, we first multiply the weight of the child (10 kg) by the ordered rate (40 ml/kg) which gives us 400 ml over 4 hours. To convert this to ml per hour, we divide 400 ml by 4 hours, resulting in 100 ml/hour. This calculation ensures the child receives the correct amount of fluid over the specified time frame. Other choices are incorrect because they do not follow the correct calculation method or do not align with the physician's order.
You may also like to solve these questions
A hospitalized 2-year-old child who has a tantrum when a parent leaves
A nurse is caring for a hospitalized 2-year-old child who has a tantrum when a parent leaves. Which of the following actions should the nurse take?
- A. Give the child a stuffed animal.
- B. Inform the child that her parent will be back in 2 hr.
- C. Call the parent to return to the child's room.
- D. Leave the child alone in the room for 5 min.
Correct Answer: A
Rationale: The correct answer is A: Give the child a stuffed animal. Offering the child a stuffed animal can provide comfort and a sense of security, helping to calm the child during the parent's absence. This action promotes emotional support and may help to reduce the child's anxiety.
Other choices are incorrect:
B: Informing the child about the parent's return time may not effectively address the immediate emotional distress.
C: Calling the parent back may not be feasible or necessary for every instance of separation anxiety.
D: Leaving the child alone can exacerbate feelings of fear and abandonment, potentially escalating the tantrum.
A toddler receiving ear drops
While administering ear drops to a toddler, a nurse by pulls the auricle down and back. The mother asks, 'Why are you pulling the ear that way?' Which of the following responses should the nurse make?
- A. When I use this technique the medication will not run out of the ear.
- B. This opens the ear canal, allowing medication to reach the inner ear region.
- C. This is the safest and easiest way to administer this medication.
- D. When I use the technique, your child experiences less pain.
Correct Answer: B
Rationale: The correct answer is B: This opens the ear canal, allowing medication to reach the inner ear region. By pulling the auricle down and back, the nurse straightens the ear canal in toddlers, making it easier for the ear drops to reach the inner ear where they are most effective. This technique helps ensure that the medication is properly administered and absorbed.
Incorrect Answers:
A: When I use this technique the medication will not run out of the ear - This is incorrect because the aim of pulling the ear is not to prevent medication from running out but to facilitate its entry.
C: This is the safest and easiest way to administer this medication - This is incorrect as the safety and ease of administration are not the primary reasons for pulling the ear in this context.
D: When I use the technique, your child experiences less pain - This is incorrect as the main purpose of pulling the ear is not to reduce pain but to ensure effective delivery of the medication to the inner ear.
An infant with a large patent ductus arteriosus
A nurse is collecting data from an infant a large patent ductus arteriosus. Which of the following is clinical manifestations should the nurse expect?
- A. Machine like murmur
- B. Chronic hypoxemia
- C. Cyanosis with crying
- D. Weak pulse
Correct Answer: A
Rationale: The correct answer is A: Machine-like murmur. A patent ductus arteriosus (PDA) is a congenital heart defect where a blood vessel called the ductus arteriosus fails to close after birth, causing abnormal blood flow. The characteristic murmur associated with PDA is described as machine-like due to its continuous and loud nature. This murmur is heard best at the upper left sternal border. Other choices are incorrect because chronic hypoxemia (B) and cyanosis with crying (C) are more commonly seen in conditions like Tetralogy of Fallot or transposition of great vessels. Weak pulse (D) may be present in conditions like coarctation of the aorta.
A child who is postoperative following a tonsillectomy
A nurse is collecting data from a child who is postoperative following a tonsillectomy. Which of the following is a clinical manifestation of a hemorrhage?
- A. Drooling
- B. Continuous swallowing
- C. Poor fluid intake
- D. Increased pain
Correct Answer: B
Rationale: The correct answer is B: Continuous swallowing. This is a clinical manifestation of hemorrhage post-tonsillectomy as the child may be swallowing blood. Drooling (A) is more indicative of airway obstruction. Poor fluid intake (C) is a sign of dehydration. Increased pain (D) can be expected postoperatively but is not specific to hemorrhage.
A toddler who is scheduled to have a lumbar puncture
A nurse is caring for a toddler who is scheduled to have a lumbar puncture. Which of the following actions should the nurse take?
- A. Restrain the toddler for 1 hr after the procedure.
- B. Swaddle the toddler in a warm blanket.
- C. Ask another nurse to assist with holding the toddler in a prone position.
- D. Place the toddler in a side-lying knee-chest position
Correct Answer: D
Rationale: The correct answer is D: Place the toddler in a side-lying knee-chest position. This position helps to open up the spaces between the vertebrae, making it easier for the healthcare provider to perform the lumbar puncture. Restraint is not recommended as it can cause distress and increase the risk of complications. Swaddling in a warm blanket may not provide the necessary positioning for the procedure. Asking another nurse to assist with holding the toddler in a prone position may not be as effective in achieving the optimal positioning needed for a lumbar puncture.