A nurse is assessing a 7-year-old who has been diagnosed with acute pyelonephritis, what assessment finding requires immediate action by the nurse?
Blood pressure of 136/92 mg
Heart rate of 100 bpm
Decreased urine output
Tea-colored urine
The Correct Answer is A
A. Hypertension (blood pressure of 136/92 mm Hg) in a child with acute pyelonephritis can indicate a severe condition that may lead to renal damage or worsening kidney function. Immediate intervention is necessary to manage high blood pressure and prevent complications.
B. A heart rate of 100 bpm is within normal limits for a 7-year-old and does not require immediate action.
C. Decreased urine output is concerning and needs monitoring, but hypertension is the more urgent issue.
D. Tea-colored urine suggests hematuria or concentrated urine, which is important but not as immediately life-threatening as high blood pressure.
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Related Questions
Correct Answer is C
Explanation
A. A complete blood count is not specifically required before administering the rubella vaccine.
B. Lead screening is not related to rubella vaccination and is not required for this purpose.
C. The rubella vaccine is a live attenuated vaccine, and it is important to ensure that the patient is not pregnant because the vaccine could potentially harm the fetus. Therefore, a pregnancy test is a necessary precaution.
D. Tuberculosis screening is not related to the rubella vaccination and is not required for this purpose.
Correct Answer is ["23"]
Explanation
To calculate the IV fluid rate, first, convert the infant's weight from pounds and ounces to kilograms. There are 2.2 pounds in one kilogram. The infant weighs 16 pounds and 8 ounces, which is 16.5 pounds or approximately 7.5 kilograms when converted (16.5 pounds ÷ 2.2 pounds per kilogram). Next, multiply the infant's weight in kilograms by the prescribed amount of IV fluid, which is 6 mL/kg. This results in 45 mL (7.5 kg × 6 mL/kg). Since the fluid is to be infused over 2 hours, divide the total volume of 45 mL by 2 hours to find the rate per hour. The IV pump should be set to deliver approximately 22.5 mL/hr. After rounding to the nearest whole number, the IV pump should be set to deliver 23 mL/hr.
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