Nokea
Which assessment would the nurse report to the physician immediately?
- A. 2-month-old with a urine output of 150 mL in 24 hours
- B. 3-year-old with a urine output of 650 mL in 24 hours
- C. 8-year-old with a urine output of over 1000 mL in 24 hours
- D. 14-year-old with a urine output of 800 mL in 24 hours
Correct Answer: A
Rationale: A 2-month-old's urine output of 150 mL/24 hours is significantly below the expected 400-500 mL, indicating possible dehydration.
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A child is brought into the ED with suspected appendicitis.
- A. Left lower quadrant pain
- B. Guarding
- C. Rebound tenderness
- D. Decreased C-reactive protein
- E. Pain on lifting thigh when supine
Correct Answer: B,C,E
Rationale: Guarding, rebound tenderness, and pain on thigh lifting are signs of appendicitis; pain is in the right lower quadrant, and C-reactive protein is elevated.
The nurse knows that the child needs to consume how many milliliters of oral fluid to make up for the fluid loss?
- A. 18
- B. 36
- C. 64
- D. 81
Correct Answer: D
Rationale: For an 18-pound (8.1 kg) child, 10 mL/kg yields 81 mL of oral fluid to replace losses from one diarrheal stool.
What is the treatment of choice for a child with intussusception?
- A. A barium enema
- B. Immediate surgery
- C. IV fluids until the spasms subside
- D. Gastric lavage
Correct Answer: A
Rationale: A barium enema can often reduce intussusception by 'un-telescoping' the bowel, avoiding surgery.
What acid-base imbalance would the nurse expect to occur from this persistent vomiting?
- A. Hyperkalemia
- B. Hypernatremia
- C. Acidosis
- D. Alkalosis
Correct Answer: D
Rationale: Persistent vomiting causes loss of hydrochloric acid and sodium chloride, leading to metabolic alkalosis.
Which statement by a mother may indicate a cause of her son's vitamin C deficiency?
- A. We get our fruits from homemade preserves.'
- B. We use milk from our own goats.'
- C. We grow all our own vegetables.'
- D. We're not big meat eaters.'
Correct Answer: A
Rationale: Heating fruits for preserves destroys vitamin C, leading to deficiency.