A nurse is caring for a 3-year-old child who has had 160 mL of urine output over the past 8-hour period.
The child weighs 33 lb.
Which of the following actions should the nurse take?
Notify the provider.
Continue to monitor the client.
Perform a bladder scan at the bedside.
Provide oral rehydration fluids.
The Correct Answer is B
Normal urine output for a child is 1-2 ml/kg/hr.
The child weighs 33 lb (15 kg), so their expected urine output over an 8-hour period would be between 120 mL and 240 mL.
The child’s urine output of 160 mL falls within this range.
Choice A, Notifying the provider, is not necessary because the child’s urine output
is within the normal range.
Choice C, Perform a bladder scan at the bedside, is not necessary because there is no indication of urinary retention.
Choice D, Providing oral rehydration fluids, is not necessary because the child’s urine output is within the normal range.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Infants with spina bifida are at an increased risk of developing a latex allergy
due to repeated exposure to latex products during medical procedures.
Providing a latex-free environment can help prevent the development of an allergy.
Choice A is not correct because limiting visitors to immediate family members is not necessary for the care of an infant undergoing surgical closure of the myelomeningocele sac.
Choice B is not correct because maintaining the infant in the supine position is not necessary for this procedure.
Choice D is not correct because initiating contact precautions is not necessary for this procedure.
Correct Answer is D
Explanation
The correct answer is d. Modify the environment.
Rationale for each choice:
Choice a. Improve the client's communication skills.
- Statement:While communication is important,it is not the priority for a child with hemiplegic cerebral palsy.
- Rationale:Hemiplegic cerebral palsy primarily affects motor skills,not communication abilities.While some children with hemiplegic cerebral palsy may have speech difficulties,it is not the most pressing concern in this case.Addressing environmental barriers to promote mobility and independence takes precedence.
Choice b. Provide respite services for the parents.
- Statement:Respite services can provide valuable support for parents,but they are not the priority in this case.
- Rationale:The focus of the care plan should be on the child's immediate needs and safety.Modifying the environment to enhance the child's functional abilities is crucial for their development and well-being.
Choice c. Foster self-care activities.
- Statement:Encouraging self-care is essential,but it requires a supportive environment.
- Rationale:Before promoting self-care activities,the nurse must ensure the child has the necessary accommodations and modifications in place to facilitate independence.
Choice d. Modify the environment.
- Statement:This is the priority goal for a child with hemiplegic cerebral palsy.
- Rationale:Modifying the home environment can significantly improve the child's mobility,safety,and ability to participate in daily activities.Examples of modifications include:
- Installing grab bars in the bathroom
- Widening doorways
- Removing tripping hazards
- Providing adaptive equipment such as special chairs or utensils
- Ensuring adequatelighting
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today