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
Choice A rationale:
Examining for the presence of any flexion of the hips when the infant is lying on the abdomen is a method to assess for Ortolani and Barlow signs, which indicate hip dislocation, not hip dysplasia.
Choice B rationale:
Extension of the legs while stimulating the stepping reflex is a normal developmental response and is not specific to hip dysplasia.
Choice C rationale:
The Babinski reflex is related to neurological development and not directly linked to hip dysplasia.
Choice D rationale:
Asymmetrical gluteal folds and unequal leg length are common findings in congenital hip dysplasia. Hip dysplasia involves improper formation of the hip joint, leading to instability and deformity of the hip socket, which can result in these physical characteristics.
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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