The parents state that he has not voided in several hours. Inspection of the penis reveals edema, redness, and the foreskin is behind the glans penis. Based on this assessment, what would the nurse anticipate as the priority action?
Perform an ultrasound to determine if there is urinary retention.
Ask the parents specifically how long the infant has not voided.
Alert the ER physician to the patient’s condition.
Continue to monitor the patient in the ER setting.
The Correct Answer is C
Choice A reason:
Performing an ultrasound to determine if there is urinary retention is not the immediate priority action. While an ultrasound can help assess urinary retention, the presence of edema, redness, and the foreskin being behind the glans penis suggests a condition known as paraphimosis. Paraphimosis is a medical emergency that requires prompt attention to prevent complications such as tissue damage. Therefore, alerting the ER physician is the priority action.
Choice B reason:
Asking the parents specifically how long the infant has not voided is important for gathering information, but it is not the immediate priority action. The clinical signs of edema, redness, and the foreskin being behind the glans penis indicate a potential emergency that requires immediate medical intervention. While obtaining a detailed history is important, the nurse should first alert the ER physician to ensure timely management.
Choice C reason:
Alerting the ER physician to the patient’s condition is the correct priority action. The presence of edema, redness, and the foreskin being behind the glans penis suggests paraphimosis, which is a urological emergency. Prompt intervention is necessary to reduce the foreskin and restore normal blood flow to prevent tissue damage3. The ER physician can provide the necessary treatment and management for this condition.
Choice D reason:
Continuing to monitor the patient in the ER setting is not appropriate without first addressing the potential emergency. The signs of edema, redness, and the foreskin being behind the glans penis indicate a condition that requires immediate medical attention. Monitoring alone is insufficient; the nurse must alert the ER physician to ensure prompt intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason:
Offering peanut butter and water is not the best immediate action for treating hypoglycemia. Peanut butter is a protein-rich food that takes longer to digest and does not quickly raise blood sugar levels. Water does not contain any carbohydrates and will not help in raising blood sugar levels.
Choice B Reason:
Giving one tablespoon of ice cream is not the most effective way to treat hypoglycemia. While ice cream contains sugar, it also has fat, which slows down the absorption of sugar into the bloodstream. This delay can prevent the rapid correction of low blood sugar levels.
Choice C Reason:
Giving a hard candy lollipop to lick can provide some sugar, but it is not the most efficient method for quickly raising blood sugar levels. The amount of sugar in a lollipop may not be sufficient to correct hypoglycemia, and the slow consumption may delay the necessary rise in blood sugar.
Choice D Reason:
Providing 1/2 cup of juice followed by cheese with a cracker is the best action for treating hypoglycemia. Juice contains fast-acting carbohydrates that can quickly raise blood sugar levels. Following it with cheese and a cracker provides protein and fat, which help stabilize blood sugar levels and prevent them from dropping again.
Correct Answer is B
Explanation
Choice A reason:
Assessing fluid intake is important in managing dehydration, but it is not the most critical assessment before initiating an IV infusion containing potassium chloride (KCL). Fluid intake provides information about the child’s hydration status but does not directly indicate kidney function. Since potassium can cause hyperkalemia if not properly excreted, monitoring urine output is more crucial.
Choice B reason:
Urine output is the most important assessment before initiating an IV infusion containing potassium chloride (KCL). This is because adequate urine output indicates that the kidneys are functioning properly and can excrete excess potassium. Administering potassium chloride without ensuring proper kidney function can lead to hyperkalemia, a potentially life-threatening condition. Therefore, checking urine output is essential to prevent complications.
Choice C reason:
Capillary refill is a useful assessment for evaluating peripheral perfusion and hydration status. However, it does not provide direct information about kidney function or the body’s ability to excrete potassium. While capillary refill can be part of the overall assessment, it is not the most critical factor before administering an IV infusion with potassium chloride.
Choice D reason:
The number of stools is relevant in assessing dehydration, especially if the child has been experiencing diarrhea. However, like fluid intake, it does not directly indicate kidney function. Monitoring urine output is more important before administering potassium chloride to ensure the kidneys can handle the additional potassium load.
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