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A nurse is collecting data from a 4-year-old child. Which of the following findings should the nurse expect?"
- A. Heart rate 110/min
- B. Capillary refill greater than 3 seconds
- C. Weight gain of 0.9 kg (2 lb) in a year
- D. Respiratory rate 32/min
Correct Answer: A
Rationale: A heart rate of 110 beats per minute is within the normal range for a 4-year-old child. The typical heart rate for this age is between 80 to 120 beats per minute.
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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.
A nurse in a clinic is preparing to administer pre-kindergarten vaccines to a 5-year-old child whose medical record indicates that his Immunizations are up to date. Which of the following vaccines should the nurse plan to administer?
- A. Hepatitis B (HBV)
- B. Measles
- C. mumps
- D. and rubella (MMR)
- E. Haemophilus influenzae type B (Hib)
- F. Pneumococcal conjugate vaccine (PCV)
Correct Answer: B
Rationale: The MMR vaccine is part of the pre-kindergarten immunization schedule.
A nurse is collecting data from an infant who hit her head when she fell off of a dressing table. The nurse should identify which of the following findings as indicating increased intracranial pressure?
- A. Brisk pupillary reaction to light
- B. Irritability
- C. Tachycardia
- D. Increased sensory response to painful stimuli
Correct Answer: B
Rationale: Irritability is a common early sign of increased ICP in infants. Changes in behaviour such as increased irritability or lethargy can indicate a neurological problemincluding increased pressure within the skull.
A nurse is teaching the parents of a child who has diabetes mellitus about the manifestations of hypoglycemia. Which of the following manifestations should the nurse include in the teaching?
- A. Fruity breath odor
- B. Diaphoresis
- C. Dry mucous membranes
- D. Polyuria
Correct Answer: B
Rationale: Diaphoresis is a common symptom of hypoglycemia due to the activation of the sympathetic nervous system.
A nurse is assisting with the admission of a 2-year-old toddler who has acute gastroenteritis. Which of the following actions should the nurse take first?
- A. Determine if the toddler is voiding.
- B. Request evaluation of the toddler's serum electrolytes.
- C. Initiate isotonic fluids with 20 mEq/L potassium chloride.
- D. Collect a stool sample from the toddler.
Correct Answer: A
Rationale: Assessing urine output is crucial for determining the child's hydration status. Voiding is an important indicator of kidney function and fluid balance.