A 4-year-old weighing 15 kg produces 150 mL of urine in 10 hours. What should the nurse do?

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Question 1 of 5

A 4-year-old weighing 15 kg produces 150 mL of urine in 10 hours. What should the nurse do?

Correct Answer: C

Rationale: Expected urine output is 0.5-1 mL/kg/hr. For a 15-kg child over 10 hours, 75-150 mL is within normal limits.

Question 2 of 5

A one-month-old patient, who has developmental dysplasia of the hip, is placed in a hip spica cast. The patient's mother expresses the desire to continue breastfeeding. What is the pediatric nurse's best response?

Correct Answer: C

Rationale: Breastfeeding can continue even with a hip spica cast, but proper positioning is essential to ensure comfort for both the infant and the mother.

Question 3 of 5

Maintaining the infusion rate of hyperalimentation solutions is a nursing responsibility. What side effects would you anticipate from too rapid infusion rate?

Correct Answer: D

Rationale: Too rapid infusion of hyperalimentation solutions can lead to circulatory overload due to the rapid volume expansion, which can strain the heart and lead to fluid overload. This can manifest as symptoms such as shortness of breath, crackles in the lungs, and edema. Additionally, a rapid infusion rate can cause a sudden surge in glucose levels, potentially leading to hypoglycemia due to increased insulin release in response to the elevated glucose levels. It is important for the nurse to maintain a careful and appropriate infusion rate to prevent these complications and ensure patient safety.

Question 4 of 5

A 6 months old boy presents with respiratory distress and feeding difficulty. On examination heart rate is 130/min and there is a pansystolic murmur at left lower sternal border. What is the most likely diagnosis?

Correct Answer: C

Rationale: Ventricular septal defect (VSD) commonly presents with a pansystolic murmur and symptoms of congestive heart failure in infancy.

Question 5 of 5

The Glasgow coma scale is used to .evaluate the level of consciousness in the neurological and neurological patients. The three assessment factors included in this scale are:

Correct Answer: C

Rationale: The Glasgow Coma Scale (GCS) is a neurological scale that is used to assess the level of consciousness in patients. It is based on three factors: eye opening, verbal response, and motor response. Each factor is scored on a scale of 1 to 4 or 6, with a lower total score indicating a lower level of consciousness.

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