Ped 3 Eva Madison quiz (Pre/Post)
The nurse is obtaining a health history for a patient showing signs of dehydration. Which of the following
are considered risk factors for dehydration? (select all that apply)
- Excessive Burns
Diabetic Ketoacidosis
Vomiting
Rationale:Risk factors for dehydration include the following: diarrhea (not constipation), vomiting,
decreased oral intake, sustained high fever (not hypothermia), diabetic ketoacidosis, and excessive burns.
The nurse is preparing a 5-year-old patient for a clean-catch urine specimen collection. Which of the
following demonstrates that the nurse understands developmentally appropriate communication?
- Your mommy will use a special wipe to clean your bottom and then will catch your pee-pee in a cup
when you go potty.
Rationale:It is important to explain procedures to a child in simple terms that are nonthreatening, such as
"clean," "bottom," "pee-pee," "cup," and "potty." Avoid terms that are too technical or confusing, which
may cause the child to misunderstand what is going to occur. The terms "urine," "urinate," "specimen,"
and "void" in the answers above are likely too technical for a 5-year-old to understand. Also, the term
"hat" may cause the child to expect a literal hat to be in the toilet.
The nurse is caring for a 5-year-old patient admitted with suspected dehydration. What is the daily oral
fluid maintenance requirement in milliliters for the patient weighing 45 lb? ___________ - 1510 mL
Rationale:Calculate daily maintenance fluid requirement using the 100-50-20 formula. Convert pounds to
kilograms: 45 ÷ 2.2 = 20.5 kg. Multiply 100 by the first 10 kg: 100 × 10 = 1,000. Multiply 50 by the
second 10 kg: 50 × 10 = 500. Multiply 20 by the remaining 0.5 kg: 20 x 0.5 = 10. Add the sum of the
calculations together to get the daily fluid maintenance: 1,000 + 500 + 10 = 1,510.
A 5-year-old patient admitted with dehydration has an order for a urinalysis. What is the best and most
appropriate way for the nurse to collect the urine specimen?
- Midstream clean catch
Rationale:Specimen collection for a urinalysis should be obtained using aseptic technique. A midstream
clean catch is the least invasive and most appropriate method to use to obtain the urine specimen from
, this patient. A urine bag works but is most appropriate for infants and small children who are not yet
toilet trained. Sterile intermittent catheterization is invasive and not necessary in this situation.
The nurse is caring for a 5-year-old patient with dehydration and hypovolemic shock. The patient
received a 400-mL bolus of normal saline over 15 minutes. On reassessment, which of the following
findings would indicate that the patient's condition is improving?
- Increased urine output
Rationale:Following administration of an isotonic crystalloid bolus (normal saline or lactated Ringer's),
the nurse would expect to see an improvement in systemic perfusion as indicated by a decrease in heart
rate and capillary refill time and an increase in blood pressure, oxygen saturations, urine output, and
strength of peripheral pulses.
A 5-year-old patient comes to the emergency room with a 3-day history of vomiting and diarrhea. The
patient weighed 21.8 kg 1 month ago at a well-child checkup and now weighs 20.5 kg. The nurse knows
that the patient would be classified as having which of the following levels of dehydration?
- Moderate dehydration
Rationale:The patient weighed 21.8 kg prior to the illness and presented to the emergency room weighing
20.5 kg. A difference of 3% to 4% weight loss indicates mild dehydration, 6% to 8% indicates moderate
dehydration, and 10% or greater indicates severe dehydration. The patient lost 1.3 kg of weight. To
determine what percentage of weight the patient has lost, divide the amount lost by the starting weight:
1.3 ÷ 21.8 = .059633 kg. Move the decimal two places to the right to convert the number to a percentage
and round to the nearest whole number: 6%. Thus, the change in the patient's weight equals a 6% weight
loss, so the patient is moderately dehydrated.
A nurse caring for a 5-year-old patient admitted with dehydration has an order to collect a stool specimen
to test for ova and parasites. The patient is ambulatory and has a recent history of diarrhea and vomiting.
What is the best method to use to collect the stool specimen from this patient?
- Have the patient urinate first and then place a clean container under the seat at the back of the toilet to
collect the specimen.
Rationale:For ambulatory patients, the patient must first urinate in the toilet, and then the stool specimen
may be retrieved from the new or clean collection container that fits under the seat at the back of the
toilet. It is important to keep urine from contaminating the stool specimen. For the bedridden patient, the
stool specimen should be collected using a clean bedpan, but this patient is ambulatory. If the patient is in
diapers, the stool specimen may be collected by scraping the specimen into a container with a tongue
blade. If the patient is diapered and has runny stools, the specimen can be collected utilizing a piece of
The nurse is obtaining a health history for a patient showing signs of dehydration. Which of the following
are considered risk factors for dehydration? (select all that apply)
- Excessive Burns
Diabetic Ketoacidosis
Vomiting
Rationale:Risk factors for dehydration include the following: diarrhea (not constipation), vomiting,
decreased oral intake, sustained high fever (not hypothermia), diabetic ketoacidosis, and excessive burns.
The nurse is preparing a 5-year-old patient for a clean-catch urine specimen collection. Which of the
following demonstrates that the nurse understands developmentally appropriate communication?
- Your mommy will use a special wipe to clean your bottom and then will catch your pee-pee in a cup
when you go potty.
Rationale:It is important to explain procedures to a child in simple terms that are nonthreatening, such as
"clean," "bottom," "pee-pee," "cup," and "potty." Avoid terms that are too technical or confusing, which
may cause the child to misunderstand what is going to occur. The terms "urine," "urinate," "specimen,"
and "void" in the answers above are likely too technical for a 5-year-old to understand. Also, the term
"hat" may cause the child to expect a literal hat to be in the toilet.
The nurse is caring for a 5-year-old patient admitted with suspected dehydration. What is the daily oral
fluid maintenance requirement in milliliters for the patient weighing 45 lb? ___________ - 1510 mL
Rationale:Calculate daily maintenance fluid requirement using the 100-50-20 formula. Convert pounds to
kilograms: 45 ÷ 2.2 = 20.5 kg. Multiply 100 by the first 10 kg: 100 × 10 = 1,000. Multiply 50 by the
second 10 kg: 50 × 10 = 500. Multiply 20 by the remaining 0.5 kg: 20 x 0.5 = 10. Add the sum of the
calculations together to get the daily fluid maintenance: 1,000 + 500 + 10 = 1,510.
A 5-year-old patient admitted with dehydration has an order for a urinalysis. What is the best and most
appropriate way for the nurse to collect the urine specimen?
- Midstream clean catch
Rationale:Specimen collection for a urinalysis should be obtained using aseptic technique. A midstream
clean catch is the least invasive and most appropriate method to use to obtain the urine specimen from
, this patient. A urine bag works but is most appropriate for infants and small children who are not yet
toilet trained. Sterile intermittent catheterization is invasive and not necessary in this situation.
The nurse is caring for a 5-year-old patient with dehydration and hypovolemic shock. The patient
received a 400-mL bolus of normal saline over 15 minutes. On reassessment, which of the following
findings would indicate that the patient's condition is improving?
- Increased urine output
Rationale:Following administration of an isotonic crystalloid bolus (normal saline or lactated Ringer's),
the nurse would expect to see an improvement in systemic perfusion as indicated by a decrease in heart
rate and capillary refill time and an increase in blood pressure, oxygen saturations, urine output, and
strength of peripheral pulses.
A 5-year-old patient comes to the emergency room with a 3-day history of vomiting and diarrhea. The
patient weighed 21.8 kg 1 month ago at a well-child checkup and now weighs 20.5 kg. The nurse knows
that the patient would be classified as having which of the following levels of dehydration?
- Moderate dehydration
Rationale:The patient weighed 21.8 kg prior to the illness and presented to the emergency room weighing
20.5 kg. A difference of 3% to 4% weight loss indicates mild dehydration, 6% to 8% indicates moderate
dehydration, and 10% or greater indicates severe dehydration. The patient lost 1.3 kg of weight. To
determine what percentage of weight the patient has lost, divide the amount lost by the starting weight:
1.3 ÷ 21.8 = .059633 kg. Move the decimal two places to the right to convert the number to a percentage
and round to the nearest whole number: 6%. Thus, the change in the patient's weight equals a 6% weight
loss, so the patient is moderately dehydrated.
A nurse caring for a 5-year-old patient admitted with dehydration has an order to collect a stool specimen
to test for ova and parasites. The patient is ambulatory and has a recent history of diarrhea and vomiting.
What is the best method to use to collect the stool specimen from this patient?
- Have the patient urinate first and then place a clean container under the seat at the back of the toilet to
collect the specimen.
Rationale:For ambulatory patients, the patient must first urinate in the toilet, and then the stool specimen
may be retrieved from the new or clean collection container that fits under the seat at the back of the
toilet. It is important to keep urine from contaminating the stool specimen. For the bedridden patient, the
stool specimen should be collected using a clean bedpan, but this patient is ambulatory. If the patient is in
diapers, the stool specimen may be collected by scraping the specimen into a container with a tongue
blade. If the patient is diapered and has runny stools, the specimen can be collected utilizing a piece of
