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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Avoid a diet consisting of primarily milk. Milk, especially cow’s milk, is low in iron and can inhibit iron absorption. Excessive milk consumption can also lead to iron deficiency anemia by displacing iron-rich foods from the diet and potentially causing gastrointestinal bleeding in infants. Limiting milk intake and ensuring a balanced diet can help prevent iron deficiency.
B. Include whole grains and legumes in the diet. Whole grains and legumes are good sources of nonheme iron, which is beneficial for preventing iron deficiency anemia. While this is a good dietary recommendation, infants might not consume enough of these foods to meet their iron needs without additional sources or supplements.
C. Administer fat-soluble vitamins daily. Rationale: Fat-soluble vitamins (A, D, E, K) are not directly related to preventing iron deficiency anemia. They are important for other aspects of health, but they do not address iron intake or absorption.
D. Limit intake of high-protein foods. Rationale: High-protein foods like meat are often rich in heme iron, which is easily absorbed and important for preventing anaemia. Limiting these foods would not be beneficial and might even contribute to anemia.
Correct Answer is B
Explanation
A. Maintain medical asepsis during dressing changes: While cleanliness is important, aseptic (sterile) technique is typically required for burn care to prevent infection.
B. Administer pain medication 30 min to 1 hour before physical therapy: Pain management is crucial to facilitate participation in physical therapy and improve outcomes.
C. Allow the child to set her own schedule for care: A structured schedule is necessary to ensure regular treatment and care for burns.
D. Provide low-calorie snacks: High-calorie, protein-rich foods are necessary to meet increased metabolic demands for healing.
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