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

Answer and Explanation

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.

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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.

A. Modeling clay B. Brightly-colored mobile C. 100-piece jigsaw puzzle D. Checkerboard and checkers

Correct Answer is A

Explanation

A. Modeling clay: Correct. This is appropriate for a 4-year-old, helping with fine motor skills and creativity.

B. Brightly-colored mobile: Incorrect. More suitable for infants who are visually stimulated by simple, moving objects.

C. 100-piece jigsaw puzzle: Incorrect. Too complex for a 4-year-old; age-appropriate puzzles typically have fewer pieces.

D. Checkerboard and checkers: Incorrect. This is better suited for older children who understand rules and strategies.

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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?

Nursing Test Bank

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