Which finding in a 5-year-old child diagnosed with hemolytic uremic syndrome would require the nurse to take immediate action?
BUN 14 mg/dL.
Serum Creatinine 0.4 mg/dL.
Urine output 76 mL/24 hours.
Hbg 12 g/dL.
The Correct Answer is C
Urine output 76 mL/24 hours.
Choice A rationale:
BUN (Blood Urea Nitrogen) of 14 mg/dL falls within the normal range (7-20 mg/dL) and is not an immediate concern.
Choice B rationale:
Serum Creatinine of 0.4 mg/dL is also within the normal range (0.2-0.5 mg/dL) and does not warrant immediate action.
Choice C rationale:
Urine output of 76 mL/24 hours is significantly decreased from the expected normal range (1-2 mL/kg/hour), indicating potential kidney dysfunction or dehydration. This requires immediate action to assess the child's hydration status and kidney function.
Choice D rationale:
Hb (Hemoglobin) of 12 g/dL is within the normal range for a 5-year-old child (11.5-15.5 g/dL) and does not necessitate urgent intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
"Does the child have a sore throat currently?”. This choice is important but not the most critical question. The surgery involves tonsillectomy and adenoidectomy, so the child's current sore throat might not be as pertinent as other factors.
Choice B rationale:
"Do the caregivers have soft foods at home for the child?”. This choice is important for post-operative care, but the most crucial consideration is the child's fasting status before surgery.
Choice C rationale:
"When was the last time the child ate or drank anything?”. This choice is correct. It is essential to determine the child's fasting status before surgery to prevent potential complications related to anesthesia and surgery.
Choice D rationale:
"Does the child have any questions about the procedure?”. While ensuring the child's understanding is important, it is not the most critical question regarding preparation for the surgery.
Correct Answer is D
Explanation
Choice D rationale:
Preschool-aged children may fear pain and bleeding, and applying a small dressing after venipuncture helps alleviate anxiety. It provides a sense of control and comfort, as the child perceives their active participation in caring for the site.
Choice A rationale:
Showing the needle and syringe might intensify anxiety in the child, making venipuncture more distressing. It's important to minimize any distress during the procedure.
Choice B rationale:
Allowing the child to help cleanse the site could lead to more anxiety as the child might interpret it as their own responsibility for the procedure.
Choice C rationale:
Encouraging the child to show the site to adults may not be reassuring for the child and could potentially exacerbate their apprehension.
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