the nurse suspects fluid overload in an infant receiving intravenous fluids what clinical manifestation is suggestive of water intoxication
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Nursing Elites

ATI RN

RN Nursing Care of Children Online Practice 2019 A

1. The nurse suspects fluid overload in an infant receiving intravenous fluids. What clinical manifestation is suggestive of water intoxication?

Correct answer: C

Rationale: Water intoxication can lead to cerebral edema, causing neurological symptoms such as irritability and seizures. Oliguria, weight loss, and muscle weakness are not typical signs of water intoxication.

2. Examination of the abdomen is performed correctly by the nurse in which order?

Correct answer: D

Rationale: The correct order for abdominal examination is inspection, auscult

3. Several types of long-term central venous access devices are used. What is a benefit of using an implanted port (e.g., Port-a-Cath)?

Correct answer: C

Rationale: Implanted ports like the Port-a-Cath are fully implanted under the skin, allowing the child to maintain regular physical activities, including swimming, without the risk of dislodging the catheter. Piercing the skin is still required for access, and self-administration is more complex.

4. What is a common sign of moderate dehydration in children?

Correct answer: A

Rationale: Dry mucous membranes are a common sign of moderate dehydration in children, indicating a loss of bodily fluids. When a child is moderately dehydrated, the mucous membranes in the mouth and nose may appear dry. This condition can occur due to various factors such as vomiting, diarrhea, or inadequate fluid intake. Normal capillary refill (choice B) is not typically associated with dehydration; it is a measure of circulatory status. Hyperactive bowel sounds (choice C) can be present in conditions like gastroenteritis but are not specific to dehydration. Edema (choice D) is the retention of fluid in the body and is not a typical sign of dehydration.

5. Which information about hemophilia will the nurse include in the teaching plan for the parents of a child diagnosed with hemophilia?

Correct answer: B

Rationale: The correct answer is B: Hemophilia is an X-linked recessive disorder, primarily affecting males and passed from mothers to sons. It involves a deficiency in clotting factors, leading to prolonged bleeding. Choice A is incorrect as hemophilia is not autosomal dominant. Choice C is incorrect as hemophilia does not involve platelets. Choice D is incorrect as hemophilia is not autosomal recessive.

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