Difficulty: Medium
Average Score: 67%
Simulated
Passage / Scenario
Nurses' Notes: 0700: 7 year old client who weighs 18.1 kg (39.9 lb) admitted with a UTI. Child reports pain and burning upon urination and feeling like they need to go to the bathroom all the time. Child's guardian reports the client has been incontinent of urine the past 2 nights and that the urine has a very strong odor. Vital Signs: 0715: Temperature 38 C (100.4 F), Heart rate 80/min, Respiratory rate 22/min, Blood pressure 106/65 mm Hg. 0930: Temperature 38.4 C (101.1 F), Heart rate 90/min, Respiratory rate 23/min, Blood pressure 105/65 mm Hg. Provider Prescription: Sulfamethoxazole and trimethoprim 8 mg TMP/kg/day PO, Salicylic acid 20 mg/kg/dose every 4 hr as needed for pain and fever.For each of the following interventions, click to specify if the potential intervention is anticipated or contraindicated for the client.
Correct answer
A,B,E
Rationale
[Explanation: Administering Sulfamethoxazole and trimethoprim is indicated for treating infections. Advising about sunscreen is important for sun protection. Educating about perineal hygiene is crucial for personal hygiene. The other choices are contraindicated for various reasons: administering salicylic acid can be harmful in children, limiting fluid intake without appropriate assessment can lead to dehydration.]