a nurse is planning to care for a child who has severe diarrhea. Which of the following actions is

the nurse's priority?

A. Introduce a regular diet

B. Rehydrate

C. Maintain fluid therapy

D. Assess fluid balance (Assess first the other three are interventions, before you intervene you

have to assess how much fluid imbalance. Check for lab results because it will tell you what

kind of fluid is to be given and how much fluid to be replaced. Priority is assessment first)

A nurse is caring for a toddler who’s parent states that the child has a mass in his abdominal

area and his urine is a pink color. Which of the following actions is the nurse’s priority?

A. Schedule the child for an abdominal ultrasound

B. Instruct the parent to avoid pressing on the abdominal area

C. Determine if the child is having pain

D. Obtain a urine specimen for a urinalysis

A nurse is caring for a child who has acute glomerulonephritis. Which of the following actions is

the nurse’s priority?

A. Place the child on a no salt added diet

B. Check the Child's weight daily

C. Educate the parents about potential complications

D. Maintain a saline lock (IV access that is attached to any fluids. For emergency)

(inflammation of the kidneys caused by group A beta hemolytic streptococcus, infection. Fluid or

fluid retention. Patients with kidney problems affect blood pressure -> High blood pressure

because of fluid retention. Salt increases high blood pressure. Lower the salt intake of this

patient)

A nurse is caring for a child who has a suspected diagnosis of bacterial meningitis. Which of the

following is the nurse’s priority?

A. Administer antibiotics when available

B. Reduce environmental stimuli (because of increase of ICP and can cause seizures)

C. Document intake and output

D. Maintain seizure precautions

A nurse is collecting data from an adolescent. Which of the following represents the greatest

risk for suicide?

A. Availability of firearms

B. Family conflict

C. Homosexuality

D. Active psychiatric disorder (Mark, mental problems, patients mind is unstable)

A nurse is collecting data from an infant who has otitis media (middle ear infection). The nurse

should expect which of the following findings?

A. Tugging on the affected ear lobe