Nokea
The nurse is talking with the parent of a pediatric client with type 1 diabetes mellitus who has influenza. Which of the following statements by the parent would require follow-up?
- A. I should encourage my child to drink more fluids.
- B. I will check my child's capillary blood glucose level more frequently.
- C. I should regularly check my child's urine for ketones.
- D. I will decrease my child's prescribed dose of insulin if my child is unable to eat.
Correct Answer: D
Rationale: Decreasing insulin during illness can lead to hyperglycemia or ketoacidosis, as insulin needs may increase.
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The nurse is calculating a client's intake and output for the shift. How many mL should the nurse record as the client's output?
Correct Answer: 208
Rationale: Emesis (120 mL) plus diaper output (50-30=20 mL, 52-30=22 mL, 46-30=16 mL) totals 120+20+22+16=208 mL.
The nurse is caring for a 2 month-old infant with a congenital heart defect. Which of the following is a priority nursing action?
- A. Provide small feedings every 3 hours
- B. Maintain intravenous fluids
- C. Add strained cereal to the diet
- D. Change to reduced calorie formula
Correct Answer: A
Rationale: Infants with congenital heart defects are at increased risk for developing congestive heart failure. Infants with congestive heart failure have an increased metabolic rate and require additional calories to grow. At the same time, however, rest and conservation of energy for eating is important. Feedings should be smaller and every 3 hours rather than the usual 4 hour schedule.
The nurse is observing continuous cardiac monitoring for assigned clients. Which of the following cardiac rhythms would immediate follow-up?
Correct Answer: C
Rationale: Ventricular fibrillation (VF) is a lethal dyshythmia characterized by disorganized electrical activity in the heart ventricles. Because
of this erratic electrical activity, the heart muscles lose the ability to contract, resulting in loss of blood flow and pulse (ie, cardiac
arrest). Nurses who identify a client with VF should immediately check the pulse, start CPR, and prepare the client for defibrillation
The nurse is to observe the client for shock. The client's admitting vital signs are blood pressure (BP)=116/70, pulse=86, and respirations=24. Which finding, if observed, would be most suggestive of shock?
- A. BP=140/60
- B. Pulse=100
- C. BP=114/68
- D. Pulse=60
Correct Answer: B
Rationale: Increased pulse (tachycardia) is a hallmark of shock, compensating for reduced volume. Stable or slightly varied BP and low pulse are less indicative.
An 8-year-old child is admitted to the hospital with pneumonia. The child has had frequent respiratory infections. A chloride sweat test is ordered. The nurse knows that the reason for this test is to rule out which condition?
- A. Pernicious anemia
- B. Diabetes insipidus
- C. Cystic fibrosis
- D. Glomerulonephritis
Correct Answer: C
Rationale: Frequent respiratory infections and pneumonia suggest cystic fibrosis, diagnosed via chloride sweat test, which detects elevated sweat chloride levels.