An assistive personnel (AP) on a pediatric unit brings to the attention of the nurse several client measurements obtained with the morning
vital signs. Which of the following clients should the nurse plan to visit first
...
An assistive personnel (AP) on a pediatric unit brings to the attention of the nurse several client measurements obtained with the morning
vital signs. 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
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