Answer to Question 1
D
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A Incorrect: Before administering intravenous fluids containing potassium, the most important thing for the nurse to check is not if respirations are over 14.
B Incorrect: Before administering intravenous fluids containing potassium, the most important thing for the nurse to check is not that the child does not have a low-grade fever.
C Incorrect: Before administering intravenous fluids containing potassium, the most important thing for the nurse to check is not that there is no nausea present. Potassium is not given to treat nausea.
D Correct: The nurse is preparing to administer intravenous fluids containing potassium for a child who is dehydrated. The most important thing for the nurse to check before administering the potassium if that the child is able to void at least 1 to 2 milliliters per kilogram per hour. Children who are dehydrated are oliguric and can become anuric. These children will not be able to excrete electrolytes that are in an IV solution and cause elevated serum potassium. An elevated serum potassium can cause cardiac irritability and ventricular fibrillation.
Answer to Question 2
B
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A Incorrect: The nurse knows that the loss of the ability to produce tears does not indicate a fluid loss of at least 1 percent of the child's body weight.
B Correct: The nurse is assessing a child who is dehydrated. The child begins to cry, but there are no tears. The nurse knows that the loss of the ability to produce tears indicates a fluid loss of at least 5 percent of the child's body weight
C Incorrect: The nurse knows that the loss of the ability to produce tears does not indicate a fluid loss of at least 8 percent of the child's body weight.
D Incorrect: The nurse knows that the loss of the ability to produce tears does not indicate a fluid loss of at least 10 percent of the child's body weight.