Nokea
The nurse is caring for a 2-year-old child who was admitted for dehydration due to gastroenteritis. The child is now receiving IV fluids and appears more alert. What is the best indicator that the child's condition is improving?
- A. The child is more alert and playful
- B. The child's urine output has increased
- C. The child's vital signs are stable
- D. The child is tolerating small amounts of oral fluids
Correct Answer: B
Rationale: Increased urine output is a reliable indicator that hydration status is improving. While alertness and playfulness are positive signs, increased urine output directly reflects improved hydration. Stable vital signs are important but may not directly indicate hydration status. Tolerating small amounts of oral fluids is a good sign but may not be as direct an indicator as increased urine output.
You may also like to solve these questions
During a follow-up clinical visit, a mother tells the nurse that her 5-month-old son, who had surgical correction for tetralogy of Fallot, has rapid breathing, often takes a long time to eat, and requires frequent rest periods. The infant is not crying while being held, and his growth is in the expected range. Which intervention should the nurse implement?
- A. Stimulate the infant to cry to produce cyanosis
- B. Auscultate the heart and lungs while holding the infant
- C. Evaluate the infant for failure to thrive
- D. Obtain a 12-lead electrocardiogram
Correct Answer: B
Rationale: Auscultating the heart and lungs while the infant is held is the most appropriate intervention to assess his current condition. This action allows the nurse to gather important information regarding the cardiovascular and respiratory status of the infant, which is crucial in evaluating his post-surgical recovery and overall well-being. Option A is incorrect as stimulating the infant to cry intentionally is not necessary and could cause distress. Option C is incorrect as the infant's growth is within the expected range, indicating no signs of failure to thrive. Option D is incorrect as obtaining a 12-lead electrocardiogram is not the initial intervention needed in this situation; assessing the heart and lungs through auscultation is more immediate and informative.
A 10-year-old child is admitted with diabetic ketoacidosis (DKA). Which laboratory value should the practical nurse (PN) anticipate?
- A. Elevated blood glucose.
- B. Decreased serum ketones.
- C. Low urine glucose.
- D. High bicarbonate levels.
Correct Answer: A
Rationale: In a case of diabetic ketoacidosis (DKA), the primary feature is elevated blood glucose levels due to insulin deficiency. Additionally, ketones are increased in the blood and urine. Bicarbonate levels are usually low because of the metabolic acidosis that accompanies DKA. Therefore, the practical nurse should anticipate elevated blood glucose levels as a characteristic laboratory finding in a child admitted with DKA. Choice B is incorrect because serum ketones are increased in DKA. Choice C is incorrect because in DKA, urine glucose is typically high due to spillage of glucose into the urine. Choice D is incorrect because bicarbonate levels are usually low in DKA, not high.
The healthcare provider finds a 6-month-old infant unresponsive and calls for help. After opening the airway and finding the infant is still not breathing, which action should the provider take?
- A. Palpate femoral pulse and check for regularity.
- B. Deliver cycles of 30 chest compressions and 2 breaths.
- C. Give two breaths that make the chest rise.
- D. Feel the carotid pulse and check for adequate breathing.
Correct Answer: C
Rationale: In pediatric basic life support, for an unresponsive infant who is not breathing normally, the correct action is to give two breaths that make the chest rise. This helps provide oxygen to the infant's body and is a crucial step in resuscitation efforts for infants in distress. Choices A, B, and D are incorrect. Palpating the femoral pulse or feeling the carotid pulse is not indicated in this scenario where the infant is unresponsive and not breathing. Delivering cycles of chest compressions and breaths is not the immediate action to take; the priority is to provide two breaths to help with oxygenation.
A 9-week-old infant is scheduled for cleft lip repair. Which information is most important for the nurse to convey to the surgeon before transporting the infant to the surgical suite?
- A. Red blood cell count of 2.3 million/mm³
- B. White blood cell count of 10,000/mm³
- C. Weight gain of 2 pounds since birth
- D. Urine specific gravity is 1.011
Correct Answer: A
Rationale: The correct answer is A because a low red blood cell count may indicate anemia, which could pose risks during surgery. Anemia can affect oxygen delivery to tissues, impacting wound healing and overall surgical outcomes. The other options, such as white blood cell count, weight gain, and urine specific gravity, are less critical for immediate surgical considerations. White blood cell count is more related to infection risk postoperatively rather than immediate surgical risk. Weight gain reflects good overall growth but does not impact the immediate surgical situation. Urine specific gravity is more indicative of hydration status rather than immediate surgical risk.
When a mother of a 3-year-old boy gives birth to a baby girl and the boy asks why his baby sister is breastfeeding from their mother, how should the nurse respond? Select the option that is not appropriate.
- A. Remind him that his mother breastfed him too
- B. Clarify that breastfeeding is the mother's choice
- C. Reassure the older brother that it does not hurt his mother
- D. Explain that newborns get milk from their mothers in this way
Correct Answer: B
Rationale: Choice B is not the appropriate response in this scenario. The correct answer is choice A, which normalizes the situation for the child by reminding him that his mother breastfed him too. This response helps the older brother understand that breastfeeding is a natural and common practice for newborns, including his baby sister, just as it was for him when he was a baby. Choice B, while true, does not directly address the child's question and may not provide the same level of reassurance and normalization as choice A. Choices C and D also do not directly answer the child's question and do not provide the same level of connection and understanding as choice A.