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 D
Explanation
Evaluate their readiness to learn.
Choice A rationale:
Limiting the session to 40 minutes might not be the initial step, as it doesn't assess the patient and mother's readiness to learn. Teaching sessions should be tailored to their learning capacity, and time restrictions should come after assessing their readiness.
Choice B rationale:
Having them handle equipment is a valuable step in teaching, but it doesn't address the foundational aspect of assessing their readiness to learn. Jumping straight into equipment handling might not be effective if they are not prepared to absorb the information.
Choice C rationale:
Giving an illustrated book might engage visual learners, but without evaluating their readiness, this approach might not be the most effective starting point. Readiness assessment helps tailor teaching methods to their learning styles and capacities.
Choice D rationale:
Evaluating their readiness to learn is the best initial action. Assessing their understanding, motivation, and any barriers to learning allows the nurse to create a customized teaching plan. This approach enhances the effectiveness of subsequent teaching strategies.
Correct Answer is B
Explanation
Minimize crying.
Choice A rationale:
Encouraging attachment might be important for the child's emotional well-being, but in the immediate postoperative period after cleft lip repair, minimizing crying takes priority. Crying can place stress on the suture line and disrupt the healing process.
Choice B rationale:
Minimizing crying is crucial to prevent tension on the suture line and ensure proper healing of the cleft lip repair. Excessive crying can lead to increased pressure on the surgical site and potential complications. Elbow restraints are applied to prevent the child from touching the surgical site, so minimizing crying helps to maintain the effectiveness of these restraints.
Choice C rationale:
Restricting oral intake is not a priority in this case. While it's important to ensure the child doesn't consume anything that might harm the surgical site, it's not the highest priority action compared to preventing tension on the suture line.
Choice D rationale:
Initiating range of motion is not the priority postoperative intervention for a cleft lip repair. The primary concern at this stage is to prevent disruption of the surgical site and ensure proper healing, making minimizing crying a higher priority.
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