ATI RN
ATI Pediatrics Exam NURS 243 Spring 2014 Questions
Extract:
A 6-year-old admitted due to dehydration following a tonsillectomy 26 hours ago, with vital signs: Temperature: 100.9°F, Pulse: 150 bpm, Respiration: 28, Blood Pressure: 88/50, Pain: Throat 10.
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A nurse is providing care for a 6-year-old patient who was admitted due to dehydration following a tonsillectomy 26 hours ago. The patient's vital signs are as follows: Temperature: 100.9°F, Pulse: 150 bpm (apically), Respiration: 28, Blood Pressure: 88/50, Pain: Ears 0, Throat 10 using FACES pain scale, Weight: 40 lbs. Complete the following sentence by using the list of options as evidenced by: The patient is most at risk for:
Correct Answer: A
Rationale: The correct answer is A: Dehydration. The patient's vital signs indicate tachycardia, hypotension, and fever, which are all signs of dehydration following a tonsillectomy. The increased heart rate (150 bpm) is the body's compensatory mechanism to maintain adequate circulation due to the decreased blood pressure (88/50) caused by dehydration. The elevated temperature (100.9°F) can be a result of the body trying to fight off the dehydration-induced stress. The weight of the patient (40 lbs) is also crucial in determining the extent of dehydration. In summary, the patient is at risk for dehydration due to the postoperative state and the vital signs pointing towards fluid loss.
Choices B, C, and D are incorrect as there is no evidence in the scenario to support infection, hemorrhage, or aspiration as immediate risks for this patient.
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