A nurse is caring for a 3-year-old child who has had 160 mL of urine output over the past 8-hour period.
The child weighs 33 lb.
Which of the following actions should the nurse take?
Notify the provider.
Continue to monitor the client.
Perform a bladder scan at the bedside.
Provide oral rehydration fluids.
The Correct Answer is B
Normal urine output for a child is 1-2 ml/kg/hr.
The child weighs 33 lb (15 kg), so their expected urine output over an 8-hour period would be between 120 mL and 240 mL.
The child’s urine output of 160 mL falls within this range.
Choice A, Notifying the provider, is not necessary because the child’s urine output
is within the normal range.
Choice C, Perform a bladder scan at the bedside, is not necessary because there is no indication of urinary retention.
Choice D, Providing oral rehydration fluids, is not necessary because the child’s urine output is within the normal range.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
When determining that Bryant's traction is appropriately assembled, the nurse should observe that the buttocks is elevated slightly off of the bed.
In Bryant traction, both of the patient’s limbs are suspended in the air vertically at a ninety-degree angle from the hips and knees slightly flexed.
Choice A is incorrect because a padded sling is not used under the knee of the affected leg in Bryant traction.
Choice B is incorrect because skin straps are not used to maintain the leg in an
extended position in Bryant traction.
Choice C is incorrect because weights are not attached to a pin that is inserted into the femur in Bryant traction.
Correct Answer is C
Explanation
The correct answer is choice C.
Choice A rationale:
Yellow nasal discharge is typically associated with respiratory infections or allergies and is not a symptom of nephrotic syndrome.
Choice B rationale:
Poor appetite can be a nonspecific symptom and may be seen in various conditions, including nephrotic syndrome. However, it is not a primary indicator.
Choice C rationale:
Facial edema is a hallmark sign of nephrotic syndrome. This condition is characterized by significant swelling, particularly around the eyes and face, due to fluid retention caused by low levels of albumin in the blood.
Choice D rationale:
Irritability can be a symptom of many conditions and is not specifically indicative of nephrotic syndrome.
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