The nurse is caring for a 20 lbs (9 kg) 6 month-old with a 3 day history of diarrhea, occasional vomiting and fever. Peripheral intravenous therapy has been initiated, with 5% dextrose in 0.33% normal saline with 20 mEq of potassium per liter infusing at 35 ml/hr. Which finding should be reported to the health care provider immediately?

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Question 1 of 5

The nurse is caring for a 20 lbs (9 kg) 6 month-old with a 3 day history of diarrhea, occasional vomiting and fever. Peripheral intravenous therapy has been initiated, with 5% dextrose in 0.33% normal saline with 20 mEq of potassium per liter infusing at 35 ml/hr. Which finding should be reported to the health care provider immediately?

Correct Answer: A

Rationale: Frequent vomiting risks dehydration and electrolyte imbalance, requiring urgent reporting.

Question 2 of 5

A client has just returned to the medical-surgical unit following a segmental lung resection. After assessing the client, the first nursing action would be to

Correct Answer: D

Rationale: Monitoring oxygen saturation ensures adequate respiratory function post-lung surgery.

Question 3 of 5

A 23 year-old single client is in the 33rd week of her first pregnancy. She tells the nurse that she has everything ready for the baby and has made plans for the first weeks together at home. Which normal emotional reaction does the nurse recognize?

Correct Answer: C

Rationale: Planning for the baby reflects anticipation, typical in late pregnancy.

Question 4 of 5

A registered nurse (RN) is assigned to work at the Poison Control Center telephone hotline. In which of these cases of childhood poisoning would the nurse suggest that parents have the child drink orange juice?

Correct Answer: B

Rationale: Orange juice neutralizes mild plant toxins like philodendron; others require urgent care.

Question 5 of 5

The nurse is performing physical assessments on adolescents. What finding would the nurse anticipate concerning female growth spurts?

Correct Answer: A

Rationale: Female growth spurts typically precede males' by about 2 years (around age 11-12).

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