An assistive personnel (AP) on a pediatric unit brings to the attention of the nurse several client measurements obtained with the morning vital signs.
... [Show More] Which of the following clients should the nurse plan to visit first? a. 7-year-old client with diabetes insipidus and a urine specific gravity of 1.002
R A specific gravity of 1.002 is much lower than the expected reference range (1.005 to 1.030) and indicates urine output that is extremely dilute. The client is losing excessive water and is in danger of hypovolemia. Therefore, the nurse should plan to visit this client first.
b. 1-year-old client with roseola and a temperature of 39°C (102.2°F)
R A fever of 39°C (102.2°F) is an expected finding in a child with roseola; therefore, this is not the client that the nurse should plan to visit first.
c. 4-year-old client with status asthmaticus and a pulse oximetry of 95%
R This value, 95%, is considered within the expected range; therefore, this is not the client that the nurse should plan to visit first.
d. 10-year-old client with sickle cell anemia and a pain rating of 6 out of 10
R A pain level of 6 is not unexpected or life threatening. Therefore, this is not the client that the nurse should plan to visit first.
2. A nurse is caring for an infant who is dehydrated and requires therapy. The nurse should monitor the infant's response to therapy by a. Weighing the infant at the same time every day.
R Weight is the most sensitive indicator of hydration status for clients of all ages. Weight is the only measurement that reflects both measurable fluid balance changes and incidental fluid loss.
b. Taking the infant's vital signs every 2 hr.
R Vital signs are not a reliable indicator of hydration status.
c. Measuring the infant's head circumference twice a day.
R Measuring head circumference gives no useful information regarding the hydration status of the infant.
d. Counting the number of wet diapers every shift.
R Counting wet diapers is inadequate to accurately determine the hydration status of the infant.
3. A nurse is caring for a preterm newborn who is in an incubator. The nurse should make sure that the maximum oxygen concentration to deliver to this client is
a. 30%.
R This is a safe oxygen concentration to deliver to a preterm newborn, but not the maximum. Of course, the nurse should make sure the newborn receives the oxygen concentration the provider prescribes b. 40%.
R Oxygen concentrations higher than 40% can cause retinal damage and visual impairment. This is the maximum concentration to deliver
c. 50%.
R This is an unsafe oxygen concentration to deliver to a preterm newborn. The nurse should make sure the newborn receives the oxygen concentration the provider prescribes
d. 60%.
R This is an unsafe oxygen concentration to deliver to a preterm newborn. The nurse should make sure the newborn receives the oxygen concentration the provider prescribes.
4. A nurse is collecting data from an infant. Which of the following is a clinical manifestation of pyloric stenosis?
a. Absent bowel sounds
R Visible gastric peristaltic waves moving from the left to the right are a clinical manifestation of pyloric stenosis.
b. Increased [Show Less]