A 9-year-old child who weighs 30 kg has assessment findings of 200 mL of urine in 24 hours, creatinine 4.0 mg/dL, and blood urea nitrogen of 23 mg/dL. What is the priority nursing intervention?
Numbness and tingling feeling in her legs.
Fever of 100.4°F (38°C).
Pain at the incision site.
Sleeping with occasional snoring.
The Correct Answer is A
Choice A rationale:
Collaborating with the team to begin peritoneal dialysis is the priority nursing intervention for a 9-year-old child with assessment findings of low urine output, high creatinine, and elevated blood urea nitrogen. These indicators suggest acute kidney injury, and initiating peritoneal dialysis is crucial to remove waste products and excess fluids.
Choice B rationale:
Strictly monitoring intake and output is important, but the child's current lab values and condition indicate the need for more immediate intervention through dialysis.
Choice C rationale:
Ensuring a low-sodium, low-phosphorus, and low-protein diet is important for renal health, but it's not the priority over addressing the acute kidney injury.
Choice D rationale:
Monitoring blood pressure is relevant but does not address the acute kidney injury that requires immediate attention. Assessment Findings for Adolescent Client:
Choice A rationale:
Numbness and tingling feeling in her legs require immediate action. These symptoms could indicate nerve compression or compromised blood flow due to the rod placement and need prompt assessment to prevent complications.
Choice B rationale:
A fever of 100.4°F (38°C) after surgery is common and can be managed with appropriate interventions, but it's not the most urgent concern in this case.
Choice C rationale:
Pain at the incision site is expected after surgery and should be managed appropriately, but it's not an immediate priority over potential neurovascular issues.
Choice D rationale:
Sleeping with occasional snoring might be related to anesthesia or positioning but doesn't require immediate action compared to the potential complications indicated by numbness and tingling.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Monitoring the stool consistency is a crucial nursing action to assess the effectiveness of pancreatic enzyme replacement therapy. Patients with pancreatic insufficiency, such as those with cystic fibrosis, may have difficulty digesting fats properly. Improved stool consistency, specifically a reduction in greasy and foul-smelling stools, indicates that the pancreatic enzymes are aiding in fat digestion.
Choice B rationale:
Pupillary reflex response assessment is unrelated to pancreatic enzyme replacement therapy. It is more commonly performed to assess neurological status or the effects of medications affecting the autonomic nervous system.
Choice C rationale:
Listening to breath sounds is important for assessing respiratory status, but it does not directly reflect the effectiveness of pancreatic enzyme replacement therapy.
Choice D rationale:
Auscultating the apical pulse rate is a general assessment of cardiovascular function and does not provide information about the effectiveness of pancreatic enzyme replacement therapy.
Correct Answer is C
Explanation
Choice A rationale:
Baclofen from an intrathecal pump primarily affects muscle tone and spasticity, not seizure medications .
Choice B rationale:
Baclofen use generally leads to a reduction in dystonia , not an increase. It's used to manage spasticity, not exacerbate it.
Choice C rationale:
The correct answer. Baclofen administered via an intrathecal pump is intended to reduce muscle tone and spasticity, improving mobility and comfort for patients with conditions like cerebral palsy.
Choice D rationale:
Baclofen doesn't typically cause decreased mobility . In fact, its use is expected to enhance mobility by reducing spasticity.
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