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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

Choice A rationale:

Refeeding any thrust out food to the baby is incorrect as it increases the risk of choking and aspiration. Parents should discard food that the baby has pushed out to prevent potential harm.

Choice B rationale:

Avoiding the use of skin lubricants on the baby is appropriate as these products might irritate the baby's sensitive skin.

Choice C rationale:

Suctioning the baby's nose before feedings is important to ensure proper breathing and effective feeding, especially in infants with Down Syndrome who may have nasal congestion.

Choice D rationale:

Using minimal soap when bathing the baby is appropriate to prevent skin irritation. Babies have delicate skin, and excessive soap can lead to dryness and discomfort.

A. Monitor breathing pattern at 15-minute intervals. B. Insert indwelling Foley catheter for straight drainage. C. IV D5/45 NS at 100 mL/hr. D. Syrup of ipecac 30 mL, po, Stat.

Correct Answer is D

Explanation

Choice A rationale:

Monitoring the patient's breathing pattern at 15-minute intervals is crucial in an unconscious patient who may have ingested alcohol or drugs, as it helps assess their respiratory status. This intervention ensures early detection of any respiratory distress and guides necessary interventions.

Choice B rationale:

Inserting an indwelling Foley catheter for straight drainage is appropriate for unconscious patients to monitor their urinary output and renal function. This helps prevent urinary retention and complications related to inadequate urine elimination.

Choice C rationale:

Administering IV D5/45 NS at 100 mL/hr is a suitable intervention to maintain the patient's fluid and electrolyte balance. It prevents dehydration and supports hemodynamic stability.

Choice D rationale:

The nurse should question the prescription of syrup of ipecac. Ipecac is no longer recommended for use in cases of poisoning due to its potential to cause adverse effects like aspiration, electrolyte imbalances, and delayed treatment. Activated charcoal or gastric lavage may be more appropriate in this situation.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which statement by the parent of a 10-month-old infant with Down Syndrome indicates the need for further instruction about the child's home care needs?

Correct Answer is A

Explanation

A 14-year-old patient is brought unconscious to the emergency room. It is suspected that the patient has deliberately taken an overdose of acetaminophen with 1/2 pint of vodka. The healthcare provider prescribes several interventions. Which intervention should the nurse question?

Correct Answer is D

Explanation

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