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 A
Explanation
Choice A rationale:
If the pancreatic enzymes are effectively aiding in digestion for a patient with cystic fibrosis, the expected outcome would be improved absorption of nutrients and fats. This would result in normal stool consistency and color. Cystic fibrosis often impairs the pancreas' ability to produce sufficient digestive enzymes, leading to malabsorption and fatty stools. Therefore, observing normal stool consistency indicates that the enzymes are working adequately.
Choice B rationale:
The color of the patient's sclerae (the white part of the eyes) is not directly related to the effectiveness of pancreatic enzymes in cystic fibrosis. Scleral color can be affected by various factors such as jaundice, liver function, and blood disorders.
Choice C rationale:
Moist buccal mucosa (inner lining of the mouth) is not a specific indicator of the effectiveness of pancreatic enzymes. This observation could be influenced by hydration status and overall oral care.
Choice D rationale:
Glucose presence in urine is more related to diabetes management rather than the effects of pancreatic enzymes in cystic fibrosis. The absence of glucose in urine does not provide information about the efficacy of these enzymes.
Correct Answer is D
Explanation
Choice A rationale:
Ketonuria is the presence of ketones in urine and is not directly associated with vaso-occlusive crisis in sickle cell anemia. This crisis typically involves pain and ischemia in various body parts.
Choice B rationale:
Diplopia refers to double vision and is not a typical symptom of vaso-occlusive crisis. Pain, not vision changes, is the primary concern in this scenario.
Choice C rationale:
Severe abdominal pain can be a symptom of vaso-occlusive crisis in sickle cell anemia, but the patient's complaint of left elbow pain would not directly correlate with this choice.
Choice D rationale:
Hyperactive patellar reflex is the correct answer. During vaso-occlusive crisis, the body's response to pain can lead to increased muscle tone and reflexes, including hyperactive deep tendon reflexes like the patellar reflex. This is an indicator of neurologic involvement in the crisis. Remember that these rationales are intended to provide a concise understanding of the correct answers based on the information provided in the questions. Always refer to medical literature and consult with healthcare professionals for comprehensive and accurate information.
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