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A nurse is planning to monitor a client for dehydration following several episodes of vomiting and an increase in the client's temperature. Which of the following findings should the nurse identify as an indication that the client is dehydrated?
- A. Urine specific gravity 1.034.
- B. Bounding pulse.
- C. BP 46/94 mm Hg.
- D. Distended neck veins.
Correct Answer: A
Rationale: A urine specific gravity of 1.034 is higher than the normal range (1.002-1.030), indicating that the urine is more concentrated due to a lack of hydration. A bounding pulse is not typically associated with dehydration. Dehydration more commonly results in a weak, rapid pulse. A blood pressure reading of 46/94 mm Hg is not indicative of dehydration. Dehydration often leads to low blood pressure. Distended neck veins are not a typical sign of dehydration. Dehydration can lead to decreased blood volume, which would not cause distension of the neck veins.
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What symptoms should a nurse expect in a 6-week-old infant admitted for evaluation of suspected pyloric stenosis?
- A. Projectile vomiting.
- B. Effortless regurgitation.
- C. Metabolic acidosis.
- D. Distended abdomen.
Correct Answer: A
Rationale: Projectile vomiting is a common symptom in infants with pyloric stenosis. This is due to the narrowing of the pylorus, the muscular valve at the bottom of the stomach, which prevents breast milk or formula from passing through to the small intestine. Effortless regurgitation is not typically associated with pyloric stenosis. The hallmark symptom of pyloric stenosis is projectile vomiting. Metabolic acidosis is not a typical symptom of pyloric stenosis. The hallmark symptom of pyloric stenosis is projectile vomiting. While a distended abdomen can occur in some cases of pyloric stenosis, it is not the most common symptom. The hallmark symptom of pyloric stenosis is projectile vomiting.
A nurse is caring for an adolescent following the application of a plaster cast for a fractured right tibia. Which of the following actions should the nurse take?
- A. Discourage the client from ambulating.
- B. Use a hair dryer on a hot setting to dry the cast.
- C. Keep the client's leg in a dependent position.
- D. Perform a neurovascular check of the lower extremities.
Correct Answer: D
Rationale: Discouraging the client from ambulating is not the best action. While it's important to limit weight-bearing activities initially, movement is encouraged to promote circulation and prevent complications such as deep vein thrombosis. Using a hair dryer on a hot setting to dry the cast is not recommended. Heat can cause the cast to dry out and crack, and it can also burn the skin. Keeping the client's leg in a dependent position is not advisable. This can lead to increased swelling and pain, and potentially delay healing. Performing a neurovascular check of the lower extremities is the correct action. This involves assessing for pain, pallor, pulselessness, paresthesia, and paralysis. These checks are crucial for monitoring for complications such as compartment syndrome and ensuring the cast is not too tight.
A nurse is planning care for a child who has severe diarrhea. Which of the following actions is the nurse's priority?
- A. Assess fluid balance.
- B. Maintain fluid therapy.
- C. Rehydrate.
- D. Introduce a regular diet.
Correct Answer: A
Rationale: Assessing fluid balance is the priority action when caring for a child with severe diarrhea. Diarrhea can lead to significant fluid and electrolyte loss, which can result in dehydration. Early recognition and treatment of dehydration are crucial to prevent further complications. While maintaining fluid therapy is an important part of managing severe diarrhea, the first step should be to assess the child's fluid balance. Rehydration is a key part of the treatment for severe diarrhea, but it should be done after assessing the child's fluid balance. Introducing a regular diet is usually done after the acute phase of diarrhea has resolved and the child's fluid balance has been restored.
A nurse is preparing a 4-year-old child for discharge following a bilateral myringotomy with tympanostomy tube placement. The mother asks what to do if the tubes fall out. Which of the following instructions should the nurse give the parent?
- A. Gently reinsert the tubes.
- B. Call the health care clinic to report that the tubes have fallen out.
- C. Reassure the mother that the tubes will not fall out.
- D. Take the child to an emergency department.
Correct Answer: B
Rationale: It is not advisable for a parent to attempt to reinsert the tubes if they fall out. This could potentially cause harm to the child's ear. If the tubes fall out, the parent should call the healthcare clinic to report this. The healthcare provider can then decide on the appropriate next steps. It is not accurate to reassure the mother that the tubes will not fall out. Tympanostomy tubes are designed to fall out on their own after a certain period of time. Taking the child to an emergency department is not necessary unless there are signs of infection or other complications.
A nurse is providing guidance to a toddler's parent about the types of food that are part of a clear liquid diet. Which food, if suggested by the parent, would indicate that they have understood the instructions?
- A. Yogurt
- B. Gelatin
- C. Strained soup
- D. Pureed fruit
Correct Answer: B
Rationale: Yogurt is not part of a clear liquid diet. It is a dairy product and is not clear or liquid at room temperature. Gelatin is part of a clear liquid diet. This type of diet is often prescribed before medical procedures or tests, or for patients with certain digestive issues. It consists of liquids and foods that are clear and liquid at room temperature. Strained soup might be allowed on a full liquid diet, but it is not part of a clear liquid diet. Only the broth of the soup, which is clear and liquid at room temperature, would be allowed. Pureed fruit is not part of a clear liquid diet. While it is a liquid at room temperature, it is not clear.