Page 956 - Saunders Comprehensive Review For NCLEX-RN

2. Come to the clinic immediately.
3. Encourage the child to drink liquids.
4. Administer an additional dose of regular insulin.
325. A pediatrician prescribes an intravenous (IV) solution of 5% dextrose and
half-normal saline (0.45%) with 40 mEq of potassium chloride for a child
with hypotonic dehydration. The nurse performs which priority assessment
before administering this IV prescription?
1. Obtains a weight
2. Takes the temperature
3. Takes the blood pressure
4. Checks the amount of urine output
326. An adolescent client with type 1 diabetes mellitus is admitted to the
emergency department for treatment of diabetic ketoacidosis. Which
assessment findings should the nurse expect to note?
1. Sweating and tremors
2. Hunger and hypertension
3. Cold, clammy skin and irritability
4. Fruity breath odor and decreasing level of consciousness
327. A mother brings her 2-week-old infant to a clinic for a phenylketonuria
rescreening blood test. The test indicates a serum phenylalanine level of 1
mg/dL (60.5 mcmol/L). The nurse reviews this result and makes which
interpretation?
1. It is positive.
2. It is negative.
3. It is inconclusive.
4. It requires rescreening at age 6 weeks.
328. A child with type 1 diabetes mellitus is brought to the emergency
department by the mother, who states that the child has been complaining of
abdominal pain and has been lethargic. Diabetic ketoacidosis is diagnosed.
Anticipating the plan of care, the nurse prepares to administer which type of
intravenous (IV) infusion?
1. Potassium infusion
2. NPH insulin infusion
3. 5% dextrose infusion
4. Normal saline infusion
329. The nurse has just administered ibuprofen to a child with a temperature of
102° F (38.8° C). The nurse should also take which action?
1. Withhold oral fluids for 8 hours.
2. Sponge the child with cold water.
3. Plan to administer salicylate in 4 hours.
4. Remove excess clothing and blankets from the child.
330. A child has fluid volume deficit. The nurse performs an assessment and
determines that the child is improving and the deficit is resolving if which
finding is noted?
1. The child has no tears.
2. Urine specific gravity is 1.035.
3. Capillary refill is less than 2 seconds.
4. Urine output is less than 1 mL/kg/hr.

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