Nokea
The 5-year-old is receiving an IV infusion of D5 with 0.45 NaCl at 100 mL/hr. Which assessment findings suggest excessive parenteral fluid intake? Select all that apply.
- A. Dyspnea
- B. Lethargy
- C. Gastric distention
- D. Crackles in lung bases
- E. Temperature of 102°F (38.9°C)
Correct Answer: A,B,D
Rationale: A: Dyspnea indicates fluid volume overload and occurs from fluid rapidly shifting between the intracellular and extracellular compartments. B: Lethargy and change in level of consciousness can occur from fluid shifting in brain cells. C: Gastric distention can occur from excessive oral (not IV) fluid intake or infection. D: Crackles indicate fluid volume overload and occur from fluid rapidly shifting into the alveoli. E: An elevated temperature is a sign of fluid volume deficit, not excess.
You may also like to solve these questions
The newly hospitalized client admits using heroin 8 hours ago. Which assessment findings, if observed in the client, should the nurse associate with heroin withdrawal?
- A. Mental confusion, drowsiness, and hypotension
- B. Dysphoric mood, pupillary dilation, and sweating
- C. Pinpoint pupils, constipation, and urinary retention
- D. No withdrawal signs until 2 to 3 days have passed
Correct Answer: B
Rationale: Dysphoric mood, pupillary dilation, and sweating are signs of heroin withdrawal. Heroin is an opioid.
Client education by the nurse entails:
- A. Telling the client everything about his disease, what is going to happen in the course of the disease, and the outcome
- B. Giving information to the client that is accurate and understandable
- C. Telling the client that the pain he experiences might not be real
- D. Giving the client medication when pain is experienced
Correct Answer: B
Rationale: Client education entails giving the client accurate and understandable information to promote understanding and engagement in their care. The other options are either inappropriate or incomplete.
The nurse is assessing the child's ear with an otoscope prior to administering medications to treat persistent otitis media. Which assessment finding should the nurse expect?
- A. otoscope_1.PNG
- B. otoscope_2.PNG
- C. otoscope_3.PNG
- D. otoscope_4.PNG
Correct Answer: A
Rationale: A: This shows otitis media characterized by a bulging contour to the tympanic membrane, unclear ossicular landmarks, and yellowish middle ear effusion. B: This shows a perforated tympanic membrane, not otitis media. C: This shows a normal left ear tympanic membrane. The ossicular landmarks can be identified through the tympanic membrane. The nurse would not expect to see a normal tympanic membrane when the child has persistent otitis media. D: This shows the presence of a foreign body in the ear canal.
The new nurse is initiating TPN for four hospitalized pediatric clients. The experienced nurse should intervene when observing the new nurse attach the TPN infusion tubing to which IV line?
- A. The catheter inserted in the right external jugular vein of the 2-year-old
- B. The catheter inserted in the right subclavian vein of the 4-year-old
- C. The peripherally inserted IV catheter in a hand vein of the 12-year-old
- D. The PICC located in the right upper arm of the 6-year-old
Correct Answer: C
Rationale: A: The external jugular vein is a central IV access site. B: The subclavian vein is a central IV access site. C: TPN is a concentrated hypertonic solution containing glucose, vitamins, electrolytes, trace minerals, and protein. Because it is hypertonic, it should be administered through a central IV access site or a PICC. A major vein is used to avoid inflammatory reactions and venous thrombosis from the high-caloric and high-osmotic fluid. D: A PICC is a central IV access site.
A client is taking phenelzine (Nardil), and their spouse would like to bring lunch from home. Which of the following is most appropriate for the client to eat?
- A. a banana
- B. grapefruit
- C. a salami sandwich
- D. avocado slices
Correct Answer: B
Rationale: A client taking an MAO Inhibitor, such as phenelzine (Nardil), should avoid tyramine-rich foods, which includes avocados, bananas, and salami.