Vsim Eva Madison-Complex (Pre/Post)

The nurse is caring for a 5-year-old patient admitted with suspected dehydration. What is the daily oral fluid maintenance requirement in milliliters for the patient weighing 45 lb? ___________

1510 mL Rationale:Calculate daily maintenance fluid requirement using the 100-50-20 formula. Convert pounds to kilograms: 45 ÷ 2.2 = 20.5 kg. Multiply 100 by the first 10 kg: 100 × 10 = 1,000. Multiply 50 by the second 10 kg: 50 × 10 = 500. Multiply 20 by the remaining 0.5 kg: 20 x 0.5 = 10. Add the sum of the calculations together to get the daily fluid maintenance: 1,000 + 500 + 10 = 1,510.

A 5-year-old patient admitted with dehydration secondary to diarrhea and vomiting is placed on isolation precautions until the source of gastrointestinal distress is determined. Which of the following types of isolation precautions would be most appropriate for this patient?

Contact precautions Rationale:Contact isolation precautions would be most appropriate to implement when caring for a patient admitted with diarrhea and vomiting. Gowns and gloves will prevent the health care provider from coming into contact with bodily fluids until the source of gastrointestinal distress is determined. Droplet precautions are used to prevent the spread of germs from the patient by coughing or sneezing. Airborne precautions are appropriate to use when the infectious agent is spread through the air. Reverse isolation precautions are used with patients who are immunocompromised or unable to fight infection; the patient must wear a mask when leaving the room.

The nurse is assessing a 5-year-old patient with a several-day history of vomiting and diarrhea. Which of the following signs would indicate that this patient is severely dehydrated? (Select all that apply.)

Cool, mottled extremities,Deeply sunken orbits Rationale:Assessment findings with severe dehydration include deeply sunken orbits, dry oral mucosa, tenting skin, increased heart rate progressing to bradycardia, and cool, mottled, or dusky skin color with significantly delayed capillary refill.

The nurse is caring for a preschool-aged patient admitted with dehydration. Which of the following measurements is the best indicator of fluid status in this patient?

Daily weight Rationale:In children, daily weights are the best indicator of changes in fluid status. Oral intake and urine output measurements are important nursing interventions for monitoring fluid status; however, daily weights are the best indicator. Skin turgor is a measure of hydration, but it is not the single best indicator of fluid status.

The nurse is obtaining a health history for a patient showing signs of dehydration. Which of the following are considered risk factors for dehydration? (select all that apply)

Excessive Burns Diabetic Ketoacidosis Vomiting Rationale:Risk factors for dehydration include the following: diarrhea (not constipation), vomiting, decreased oral intake, sustained high fever (not hypothermia), diabetic ketoacidosis, and excessive burns.

Eva's mother asks why the health care provider ordered a stool sample. Which of the following responses by the nurse identifies the most likely rationale for the stool sample, given Eva's condition?

The lab will check the stool for parasites to see if that is why Eva is having diarrhea. Rationale:Eva's health care provider ordered a stool sample for ova and parasites to help determine the cause of Eva's diarrhea. Other diagnostic tests for stool testing, which were not ordered by the health care provider, include testing the stool for occult blood, performing a stool culture to check for the presence of bacteria, and completing a stool viral panel to assess for rotavirus and other viruses.

The charge nurse is making patient assignments for the next shift. The nurse should assign Eva to the same cohort or group of patients as which of the following?

Another child with gastroenteritis Rationale:Gastroenteritis may be viral or bacterial and can be infectious. It is best to assign children who require contact precautions, as does Eva, to a cohort or group with patients who have the same or a similar infection. Good handwashing is essential to prevent the spread. An infant with meningitis, a child with fever and neutropenia, and a child recovering from an appendectomy should not be in contact with a child who has an infectious process.

A nurse is explaining contact isolation precautions to the caregiver of a child admitted with gastroenteritis and dehydration. Which of the following statements by the caregiver indicates that teaching has been effective?

I need to wear gloves and a gown when I am in my child's room and discard them in the trash when leaving the room. Rationale:Contact precautions are used to prevent the spread of microorganisms that are spread by direct or indirect contact with the patient or the patient's environment. Effective contact precautions require a single room, if possible, and the use of gloves and gowns by anyone having contact with the patient, the patient's support equipment, or items that have come in contact with the patient or the patient's environment. Proper hand hygiene and handling and disposal of articles that have come in contact with the patient and environment are essential.

A 5-year-old patient comes to the emergency room with a 3-day history of vomiting and diarrhea. The patient weighed 21.8 kg 1 month ago at a well-child checkup and now weighs 20.5 kg. The nurse knows that the patient would be classified as having which of the following levels of dehydration?

Moderate dehydration Rationale:The patient weighed 21.8 kg prior to the illness and presented to the emergency room weighing 20.5 kg. A difference of 3% to 4% weight loss indicates mild dehydration, 6% to 8% indicates moderate dehydration, and 10% or greater indicates severe dehydration. The patient lost 1.3 kg of weight. To determine what percentage of weight the patient has lost, divide the amount lost by the starting weight: 1.3 ÷ 21.8 = .059633 kg. Move the decimal two places to the right to convert the number to a percentage and round to the nearest whole number: 6%. Thus, the change in the patient's weight equals a 6% weight loss, so the patient is moderately dehydrated.

The nurse would expect which of the following laboratory results to be elevated in a preschool-aged patient with moderate dehydration? (Select all that apply.)

Serum sodium Creatinine Urine specific gravity Blood urea nitrogen (BUN) Rationale:Blood urea nitrogen (BUN), creatinine, serum sodium level, and urine specific gravity may be elevated with a fluid volume deficit and dehydration. Serum potassium level will be decreased with loss of body fluids through vomiting and diarrhea.

The nurse is caring for 5-year-old Eva admitted with dehydration for intravenous rehydration. Eva's mother must leave the bedside to care for another child at home and asks whether the nurse can find something for the patient to play with while unsupervised. Which of the following toys would be most appropriate for the nurse to provide Eva with?

Simple jigsaw puzzle Rationale:A simple jigsaw puzzle with large pieces would be most appropriate for a preschool-aged child. An unbreakable mirror and a board book would be appropriate for an infant. A bucket and plastic shovel would be more appropriate for a toddler to use in a sandbox, not for a preschool-aged child in the hospital.

The nurse is teaching Eva how to wash her hands properly to prevent the spread of infection. Which of the following is the most developmentally appropriate language to include in the nurse's teaching?

Sing "Happy Birthday" to make sure you wash your hands for the right amount of time. Rationale:Having the child sing a familiar song like "Twinkle, Twinkle Little Star," "Happy Birthday," or the "ABC" song can ensure that hands have been washed for an adequate cleaning time. Hands should be washed for a minimum of 15 seconds; however, a 5-year-old may not understand the concept of time, so associating a song with the 15-second timeframe is more developmentally appropriate. The terms "viruses" and "bacteria" are too technical. It is important to explain procedures to a child in simple terms that are nonthreatening.

The nurse is admitting Eva, a 5-year-old with severe gastroenteritis and dehydration, to the hospital. Which of the following nursing interventions has highest priority?

Assessing Eva's heart rate, skin turgor, and last urine output Rationale:Checking heart rate, skin turgor, and last urine output is the best way for the nurse to assess dehydration, which is a primary concern. The other choices are not a high priority.

The nurse is providing Eva's mother with discharge instructions regarding diet progression. Which of the following responses by Eva's mother indicates that teaching has been effective?

Eva should drink an oral rehydration solution in small amounts until she is ready to progress to a regular diet. Rationale:For the first 24 hours, the patient should drink the oral rehydration solution prescribed by the health care provider in small, frequent amounts as the patient is able to handle it. This will help replace the fluids, salts, and sugars in the body. When the patient is able to eat, a normal, healthy diet should be offered. Milk is not appropriate for oral rehydration. Fatty foods, fried foods, and foods that are high in sugar should be avoided. Certain drinks should be avoided, such as soda, water, ginger ale, tea, fruit juice, caffeinated drinks, or sports drinks. These do not contain the right mix of sugar and salts. They can also irritate the patient's stomach, make vomiting and diarrhea worse, and increase the severity of dehydration.

A nurse caring for a 5-year-old patient admitted with dehydration has an order to collect a stool specimen to test for ova and parasites. The patient is ambulatory and has a recent history of diarrhea and vomiting. What is the best method to use to collect the stool specimen from this patient?

Have the patient urinate first and then place a clean container under the seat at the back of the toilet to collect the specimen. Rationale:For ambulatory patients, the patient must first urinate in the toilet, and then the stool specimen may be retrieved from the new or clean collection container that fits under the seat at the back of the toilet. It is important to keep urine from contaminating the stool specimen. For the bedridden patient, the stool specimen should be collected using a clean bedpan, but this patient is ambulatory. If the patient is in diapers, the stool specimen may be collected by scraping the specimen into a container with a tongue blade. If the patient is diapered and has runny stools, the specimen can be collected utilizing a piece of plastic wrap in the diaper to catch the stool or by application of a urine bag to the anal area to collect the specimen.

The nurse is preparing a 5-year-old patient for a clean-catch urine specimen collection. Which of the following demonstrates that the nurse understands developmentally appropriate communication?

Your mommy will use a special wipe to clean your bottom and then will catch your pee-pee in a cup when you go potty. Rationale:It is important to explain procedures to a child in simple terms that are nonthreatening, such as "clean," "bottom," "pee-pee," "cup," and "potty." Avoid terms that are too technical or confusing, which may cause the child to misunderstand what is going to occur. The terms "urine," "urinate," "specimen," and "void" in the answers above are likely too technical for a 5-year-old to understand. Also, the term "hat" may cause the child to expect a literal hat to be in the toilet.

A 5-year-old patient admitted with dehydration has an order for a urinalysis. What is the best and most appropriate way for the nurse to collect the urine specimen?

Midstream clean catch Rationale:Specimen collection for a urinalysis should be obtained using aseptic technique. A midstream clean catch is the least invasive and most appropriate method to use to obtain the urine specimen from this patient. A urine bag works but is most appropriate for infants and small children who are not yet toilet trained. Sterile intermittent catheterization is invasive and not necessary in this situation.

The nurse is reviewing a teaching handout with Eva's mother on home care of a child with dehydration, which includes information about when it is necessary to return to see the health care provider. Which of the following responses by Eva's mother indicates that teaching has been effective?

If Eva has diarrhea or vomiting and doesn't pee, or feels worse, the provider needs to see her. Rationale:Eva needs to return for further assessment by the health care provider if any of the following occur: she demonstrates signs of infection such as a fever of 100.4°F or higher, has dark, concentrated urine, has not urinated in more than 6 hours and is vomiting, is very sleepy or has less energy for light activities, or if the health problem does not improve or worsens. Eva's mother should not wait 48 hours since the last time Eva urinated to call the provider; she should call the provider after just 6 hours, since delaying would cause the dehydration to become more severe. Fatigue would be expected after vigorous exercise, such as actively playing at the park; the parent should be more concerned if Eva is fatigued following more passive activities such as reading or watching television.

The nurse is caring for a 5-year-old patient with dehydration and hypovolemic shock. The patient received a 400-mL bolus of normal saline over 15 minutes. On reassessment, which of the following findings would indicate that the patient's condition is improving?

Increased urine output Rationale:Following administration of an isotonic crystalloid bolus (normal saline or lactated Ringer's), the nurse would expect to see an improvement in systemic perfusion as indicated by a decrease in heart rate and capillary refill time and an increase in blood pressure, oxygen saturations, urine output, and strength of peripheral pulses.