The healthcare provider is caring for a child on bed rest who has severe edema in the left lower extremity due to blocked lymphatic drainage. Which nursing diagnosis would take priority?

Correct Answer: A

Rationale: The priority nursing diagnosis in this scenario is 'Risk for Impaired Skin Integrity' because severe edema in the left lower extremity can lead to compromised circulation and pressure ulcers, increasing the risk of skin breakdown and infection. Addressing and preventing impaired skin integrity is crucial for the child's overall health and well-being.

Correct Answer: D

Rationale: The correct answer is D) Infants' kidneys are less able to concentrate urine. This is because infants have immature renal systems compared to older children. The developing kidneys of infants are not as efficient at concentrating urine, leading to a lower specific gravity. Option A) Infants having a greater body surface area is not directly related to specific gravity but is more linked to heat regulation and drug absorption. Option B) Infants having a higher basal metabolic rate is also not directly related to specific gravity but refers to the rate at which the body uses energy at rest. Option C) Infants having a greater percentage of body weight that is water is partially correct but does not fully explain the lower specific gravity. While infants do have a higher percentage of body weight as water, the main reason for the lower specific gravity is the immaturity of their kidneys. In an educational context, understanding the differences in renal function between infants and older children is crucial for pediatric nursing. Nurses must be aware of the physiological differences in order to provide appropriate care and monitor the hydration status of infants effectively. This knowledge helps in assessing and managing fluid balance and kidney function in pediatric patients.

Correct Answer: C

Rationale: In this scenario, the correct answer is C) Increased Pain. Naloxone is an opioid antagonist used to reverse the effects of opioids, such as respiratory depression. When naloxone is administered to a patient who is opioid-dependent or has received opioids, it can precipitate acute withdrawal symptoms, including increased pain due to the sudden reversal of the analgesic effects of opioids. Option A) Drowsiness is incorrect because naloxone typically causes alertness rather than drowsiness. Option B) Tics and tremors are also not expected effects of naloxone administration. Option D) Nausea and vomiting are more commonly associated with opioid use rather than naloxone administration. In a pediatric nursing context, it is crucial for nurses to understand the pharmacological actions of medications they administer, particularly in critical situations like post-operative care. By recognizing the potential effects of naloxone, nurses can anticipate and manage adverse reactions effectively, ensuring the safety and well-being of their pediatric patients.

Correct Answer: C

Rationale: In pediatric nursing, understanding the effects of medications like furosemide (Lasix) is crucial. The correct answer is C) Decrease BP. Furosemide is a loop diuretic that works by increasing urine output, leading to fluid and electrolyte loss. This diuretic effect can result in a decrease in blood pressure due to reduced circulating volume. Option A) Decrease pulse is incorrect because furosemide does not directly affect heart rate. Option B) Decrease temperature is incorrect as furosemide does not typically impact body temperature. Option D) Decrease respiratory rate is also incorrect as furosemide does not have a direct effect on respiratory function. Educationally, it's important to understand the expected outcomes and side effects of medications used in pediatric patients to provide safe and effective care. Monitoring for changes in vital signs and clinical manifestations after administering medications like furosemide is essential to assess the drug's effectiveness and ensure patient safety. This question highlights the need for nurses to be vigilant in monitoring pediatric patients receiving diuretic therapy to prevent potential complications related to fluid and electrolyte imbalances.

Correct Answer: C

Rationale: The primary and most serious adverse effect of heparin is bleeding. However, discolored urine can indicate bleeding into the urinary tract, which is a potential adverse effect of heparin therapy. While changes in heart rate (HR) and blood pressure (BP) can occur due to various reasons, discolored urine specifically points towards a potential adverse effect related to heparin therapy.