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
Activated charcoal should be given as soon as possible to help absorb the acetylsalicylic acid in the gastrointestinal tract.
Choice A is not an answer because N-acetylcysteine is used to treat acetaminophen overdose, not acetylsalicylic acid overdose.
Choice B is not an answer because chelation therapy with deferoxamine is used to treat iron poisoning, not acetylsalicylic acid overdose.
Choice D is not an answer because inducing vomiting with syrup of ipecac is no longer recommended for the treatment of poisoning due to the potential for harm and lack of evidence of benefit.
Correct Answer is D
Explanation
a.Log rolling is an appropriate technique to reposition a postoperative scoliosis repair patient as it minimizes stress on the spine and helps maintain spinal alignment. Patients need frequent repositioning to prevent pressure ulcers and promote comfort, but every 4 hours may not be frequent enough; typically, every 2 hours is recommended.
b.Protective isolation is not typically required for patients undergoing scoliosis surgery unless they have specific risk factors for infection (e.g., immunocompromised status). Standard postoperative care focuses on monitoring for infection at the surgical site rather than isolation unless indicated by the patient's condition.
c.While it’s important to elevate the head of the bed to assist with breathing and comfort, after scoliosis surgery, the head of the bed is generally elevated to 30-45° to facilitate lung expansion and reduce the risk of aspiration. However, it should be ensured that this angle does not compromise spinal alignment, especially in the early postoperative period.
d.The use of a patient-controlled analgesia (PCA) pump is an appropriate intervention for pain management after scoliosis surgery. It allows the patient to self-administer pain medication within prescribed limits, leading to more effective pain management, improved patient satisfaction, and potentially reduced need for supplemental analgesics.
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