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A nurse is caring for a 4-year-old child who has dehydration. Which of the following findings should the nurse identify as the priority?
- A. Sodium 142 mEq/L
- B. Urine specific gravity 1.025
- C. Potassium 2.5 mEq/L
- D. Blood glucose 110 mg/Dl
Correct Answer: C
Rationale: Potassium 2.5 mEq/L is below the normal range for potassium (3.5-5.0 mEq/L) and indicates hypokalemia which can cause serious cardiac issues and muscle weakness.
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A nurse on a medical-surgical unit is caring for a group of children. Which of the following findings should alert the nurse that one of the children is a potential victim of abuse?
- A. A school-age child who cries when the nurse is giving him an injection
- B. A toddler who has multiple bruises on the shins of both legs and his parents report that he is clumsy
- C. A preschooler who has a BMI indicating obesity
- D. An adolescent who asks to stay in the hospital because he likes the room
Correct Answer: D
Rationale: This might indicate that the adolescent is not feeling safe or comfortable at home which could be a sign of abuse or neglect.
A nurse is reviewing the medical record of a toddler who has moderate dehydration. Which of the following findings should the nurse expect?
- A. Decreased hematocrit
- B. Increased respiratory rate
- C. Decreased heart rate
- D. Increased platelet count
Correct Answer: B
Rationale: Dehydration can lead to tachypnea (increased respiratory rate) as the body attempts to compensate for the decreased blood volume.
A nurse is preparing a 9-year-old child for an IV catheter insertion. Which of the following actions should the nurse take first?
- A. Ask the child what he knows about the procedure.
- B. Allow the child to see and touch IV tubing and supplies.
- C. Describe the procedure using visual aids.
- D. Explain to the child's parents what role they will have during the procedure.
Correct Answer: A
Rationale: Understanding the child's knowledge and feelings about the procedure helps tailor the explanation to address any misconceptions and reduce anxiety.
A nurse is caring for an adolescent. The nurse should expect that the adolescent is working on which of the following developmental tasks?
- A. Defining a sense of self
- B. Learning to perform tasks independently
- C. Learning to use creative energies
- D. Building a sense of trust
Correct Answer: A
Rationale: Adolescence is characterized by the search for identity and defining a sense of self. Erikson identifies this stage as "Identity vs. Role Confusion where individuals explore and form their own identity separate from their family and childhood roles.
A nurse is preparing to administer acetaminophen 15 mg/kg PO to a preschool child for fever. The child weighs 30 lb. Available is acetaminophen liquid 160 mg/5 mL. How many mL should the nurse administer? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)
- A. 6.4 mL
- B. 5.4 mL
- C. 7.4 mL
- D. 4.4 mL
Correct Answer: 6.4
Rationale: Calculation: 30 lb × 0.454 kg/lb = 13.62 kg; 15 mg/kg × 13.62 kg = 204.3 mg; 204.3 mg ÷ 160 mg/5 mL = 6.4 mL.