Nokea
The physician orders intravenous fluid replacement therapy with potassium chloride to be added for a child with severe gastroenteritis. Before adding the potassium chloride to the intravenous fluid, which of the following assessments would be most important?
- A. Ability to void.
- B. Passage of stool today.
- C. Baseline electrocardiogram.
- D. Serum calcium level.
Correct Answer: A
Rationale: Ensuring the ability to void confirms renal function before administering potassium.
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After reading the vaccine information sheets, the parent of a 2-month-old infant is hesitant to consent to the recommended vaccinations. The nurse should first ask the parent:
- A. Did you know that vaccinations are required by law for school entry?
- B. What personal beliefs or safety concerns do you have about vaccinations?
- C. Would you prefer that fewer vaccines are given at a time?
- D. Can you please sign this vaccine waiver form?
Correct Answer: B
Rationale: Addressing the parent's specific concerns fosters trust and encourages informed decision-making.
A child with celiac disease is at risk for which complication if the diet is not followed?
- A. Renal failure.
- B. Intestinal lymphoma.
- C. Pulmonary fibrosis.
- D. Cardiomyopathy.
Correct Answer: B
Rationale: Untreated celiac disease increases the risk of intestinal lymphoma due to chronic inflammation. Renal, pulmonary, or cardiac complications are not directly associated.
Which of the following nursing diagnoses would be appropriate for the nurse to identify as a priority diagnosis for an infant just admitted to the hospital with a diagnosis of gastroenteritis?
- A. Pain related to repeated episodes of vomiting.
- B. Deficient fluid volume related to excessive losses from severe diarrhea.
- C. Impaired parenting related to infant's loss of feeding pattern.
- D. Impaired urinary elimination related to increased fluid intake.
Correct Answer: B
Rationale: Fluid loss from diarrhea is the most urgent concern in gastroenteritis.
After teaching the parents of a child with febrile seizures about methods to lower temperature other than using medication, which of the following statements indicates that further teaching is necessary?
- A. We'll add extra blankets when he complains of being cold.'
- B. We'll wrap him in a blanket if he starts shivering.'
- C. We'll make the bath water cold enough to make him shiver.'
- D. We'll use a solution of half alcohol and half water when sponging him.'
Correct Answer: A,B,C,D
Rationale: All options are incorrect: blankets increase temperature, cold baths cause discomfort, and alcohol sponging is unsafe. Further teaching is needed.
Which of the following assessment findings should alert the nurse to suspect appendicitis in a male adolescent complaining of severe abdominal pain?
- A. Abdomen appears slightly rounded.
- B. Bowel sounds are heard twice in 2 minutes.
- C. All four abdominal quadrants reveal tympany.
- D. The client demonstrates a cremasteric reflex.
Correct Answer: B
Rationale: Decreased bowel sounds suggest appendicitis due to peritoneal irritation.