A nurse is caring for a 4-year-old child who has dehydration. Which of the following findings should the nurse identify as the priority?
Sodium 142 mEq/L
Urine specific gravity 1.025
Potassium 2.5 mEq/L
Blood glucose 110 mg/Dl
The Correct Answer is C
A. Sodium 142 mEq/L: This is within the normal range for sodium (135-145 mEq/L) and does not indicate a problem that needs immediate attention.
B. Urine specific gravity 1.025: This value is on the higher end of the normal range for urine specific gravity (1.010-1.030) and indicates concentration of urine, which can occur in mild dehydration. It is not critical but indicates the need for monitoring.
C. Potassium 2.5 mEq/L: This is below the normal range for potassium (3.5-5.0 mEq/L) and indicates hypokalemia, which can cause serious cardiac issues and muscle weakness. It is a priority to correct this imbalance to prevent complications.
D. Blood glucose 110 mg/dL: This is within the normal range for blood glucose levels (70-110 mg/dL) for children and does not indicate an immediate concern related to dehydration.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Fruity breath odour: This is a sign of diabetic ketoacidosis (DKA), a condition associated with hyperglycemia, not hypoglycaemia.
B. Diaphoresis: Sweating is a common sign of hypoglycemia due to the body's release of adrenaline in response to low blood sugar levels.
C. Dry mucous membranes: This is typically associated with dehydration and hyperglycemia, not hypoglycaemia.
D. Polyuria: Frequent urination is a symptom of hyperglycemia, as the body tries to excrete excess glucose through the urine.
Correct Answer is D
Explanation
A. Obtain a throat culture. Throat cultures are contraindicated in suspected epiglottitis because the procedure can provoke airway obstruction and worsen the condition.
B. Visualize the epiglottis using a tongue depressor. Attempting to visualize the epiglottis can lead to sudden airway obstruction in children with epiglottitis. This is dangerous and should be avoided.
C. Initiate airborne precautions. Droplet precautions, not airborne, are necessary for epiglottitis because it is typically caused by bacteria that spread through respiratory droplets.
D. Prepare the child for a neck X-ray and possible tracheostomy. A neck X-ray can help diagnose epiglottitis by showing the characteristic "thumb sign." Immediate airway management, including preparation for a potential tracheostomy, is crucial due to the risk of sudden airway obstruction.
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