the presence of which pair of factors is a good predictor of a fluid deficit of at least 5 in an infant
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Nursing Elites

ATI RN

RN Nursing Care of Children Online Practice 2019 A

1. The presence of which pair of factors is a good predictor of a fluid deficit of at least 5% in an infant?

Correct answer: D

Rationale: Dry mucous membranes and an ill appearance are good indicators of dehydration in infants, often correlating with a fluid deficit of at least 5%. Sunken fontanels and poor skin turgor are also indicative but were not options here.

2. A 5-year-old has patient-controlled analgesia (PCA) for pain management after abdominal surgery. What information does the nurse include in teaching the parents about the PCA?

Correct answer: C

Rationale: The correct answer is C because the PCA pump can be programmed to deliver a continuous basal rate of pain medication to maintain pain control. While the goal of PCA is effective pain relief, it does not guarantee a pain-free state. In the case of a 5-year-old child, the parents or nurse can administer boluses if necessary since the child may not fully comprehend using the PCA button. Monitoring every 1 to 2 hours for patient response is adequate and there is no need for monitoring every 15 minutes, as stated in choice D, unless specific circumstances dictate more frequent monitoring.

3. Which laboratory test would be most important for the nurse to assess when caring for a toddler suspected of having cystic fibrosis?

Correct answer: C

Rationale: The sweat chloride test is the primary diagnostic test for cystic fibrosis. Cystic fibrosis is characterized by abnormal transport of chloride and sodium across epithelial cell membranes, leading to increased chloride in sweat. This test is crucial for diagnosing cystic fibrosis in suspected cases. Liver enzymes (Choice A), serum calcium (Choice B), and urine creatinine (Choice D) are not specific tests for cystic fibrosis and would not provide the necessary information for diagnosis in this case.

4. 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.

5. A 3-year-old child was adopted immediately after birth. The parents have just asked the nurse how they should tell the child that she is adopted. Which guideline concerning adoption should the nurse use in planning a response?

Correct answer: D

Rationale: It is important to tell children about their adoption early, in an age-appropriate manner, as part of building trust and openness in the family relationship.

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