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How many mL of fluid intake should the nurse record for a client who consumed 1 cup of coffee, 4 oz of orange juice, 3 oz of water, 1 cup of flavored gelatin, 1 cup of tea, 5 oz of broth, and 3 oz of water during a 4-hour period? (Round the answer to the nearest whole number)
Correct Answer: 1170 mL
Rationale: Step 1 is to convert all fluid intake to mL. Using the conversion factor 1 oz = 30 mL and 1 cup = 240 mL, we get: 1 cup of coffee = 240 mL, 4 oz of orange juice = 4 × 30 mL = 120 mL, 3 oz of water = 3 × 30 mL = 90 mL, 1 cup of flavored gelatin = 240 mL, 1 cup of tea = 240 mL, 5 oz of broth = 5 × 30 mL = 150 mL, 3 oz of water = 3 × 30 mL = 90 mL. Step 2 is to add up all the mL values: 240 mL (coffee) + 120 mL (orange juice) + 90 mL (water) + 240 mL (gelatin) + 240 mL(tea) + 150 mL (broth) + 90 mL (water) = 1170 mL. So, the nurse should record a fluid intake of 1170 mL.
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A 10-year-old child was admitted with full-thickness burns affecting more than 15% of the child's body surface. What manifestations of hypovolemic shock would you observe for over the next 48 hrs? Select all choices that apply:
- A. Rapid pulse.
- B. Decreased B/P.
- C. Pallor.
- D. Flushed Face.
Correct Answer: A,B,C
Rationale: Choice A rationale: Rapid pulse is a common manifestation of hypovolemic shock. When the body experiences a significant loss of fluid, such as in severe burns, the heart rate increases in an attempt to maintain adequate blood flow and oxygen delivery to the body's tissues. Choice B rationale: Decreased blood pressure is another typical sign of hypovolemic shock. As the body loses fluid, the volume of blood circulating through the body decreases. This drop in blood volume leads to a decrease in blood pressure. Choice C rationale: Pallor, or paleness of the skin, can occur in hypovolemic shock. This happens because the body prioritizes sending blood to vital organs like the heart and brain, which can result in less blood flow to the skin, causing it to appear pale. Choice D rationale: A flushed face is not typically associated with hypovolemic shock. In fact, the skin may actually appear pale or cool due to reduced blood flow.
A nurse at a pediatrician's office answers a phone call from a parent whose child just ingested 15 vitamin tablets with added ferrous sulfate. Which of the following instructions should the nurse give to the parent?
- A. Administer syrup of ipecac.
- B. Give the child 120 mL (8 oz) of orange juice.
- C. Contact the poison control center.
- D. Provide the child with a high-carbohydrate snack.
Correct Answer: C
Rationale: Administering syrup of ipecac is not recommended in cases of iron overdose. Ipecac was once used to induce vomiting in cases of poisoning, but it is no longer recommended due to potential complications and lack of evidence for effectiveness. Giving the child orange juice will not help in this situation. While vitamin C can enhance iron absorption, it does not have an effect on iron that has already been absorbed into the body. Contacting the poison control center is the appropriate action. They can provide immediate advice on what to do in cases of potential iron overdose. Providing a high-carbohydrate snack will not help in this situation. It will not affect the absorption or toxicity of the iron.
A nurse is preparing to administer immunizations to a child who has an allergy to eggs. The nurse should know that an allergy to eggs is a contraindication for which of the following immunizations?
- A. Haemophilus influenza type b (Hib)
- B. Inactivated poliovirus (IPv)
- C. Hepatitis B (HepB)
- D. Influenza
Correct Answer: D
Rationale: The Haemophilus influenza type b (Hib) vaccine is not contraindicated for people with egg allergies. The Hib vaccine is used to prevent Haemophilus influenza type b, a bacteria responsible for severe pneumonia, meningitis and other invasive diseases almost exclusively in children aged less than 5 years. The Inactivated poliovirus (IPv) vaccine is not contraindicated for people with egg allergies. The IPV vaccine is used to prevent polio, a crippling and potentially deadly infectious disease. The Hepatitis B (HepB) vaccine is not contraindicated for people with egg allergies. The HepB vaccine is used to prevent hepatitis B, a viral infection that attacks the liver. The Influenza vaccine is contraindicated for people with severe egg allergies. Most flu vaccines today are produced using an egg-based manufacturing process and thus contain a small amount of egg protein called ovalbumin.
A school nurse is screening an 11-year-old child for idiopathic scoliosis. Which of the following instructions should the nurse give the child for this examination?
- A. Bend forward from the waist with your head and arms downward.
- B. Touch your chin to your chest, and then look up at the ceiling.
- C. Lie prone on the examination table.
- D. Turn to the side and remain in a relaxed position.
Correct Answer: A
Rationale: Bending forward from the waist with the head and arms downward, also known as the Adams forward bend test, is the standard screening test for scoliosis. Touching the chin to the chest and then looking up at the ceiling does not provide a view of the spine necessary for scoliosis screening. Lying prone on the examination table is not a standard position for scoliosis screening. Turning to the side and remaining in a relaxed position is not a standard position for scoliosis screening.
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.