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 B
Explanation
A. Perform range-of-motion (ROM) exercises to the infant's hips. ROM exercises are not the priority for an infant with spina bifida and could potentially cause harm if not done properly, particularly if the lesion is in a sensitive area.
B. Place the infant in a prone position. This is the correct action as it helps prevent pressure on the spina bifida lesion and minimizes the risk of injury or infection to the exposed spinal cord or meninges.
C. Feed the infant through an NG tube. An NG tube is not typically necessary for feeding infants with spina bifida unless there are other complicating factors that affect feeding.
D. Cover the infant's lesion with a dry cloth. The lesion should be covered with a sterile, moist, and non-adhesive dressing to prevent infection and keep the area moist. A dry cloth could cause the lesion to dry out and increase the risk of infection or damage.
Correct Answer is A
Explanation
A. "You should bring the infant's favourite blanket to the hospital." Bringing the infant's favourite blanket can provide comfort and a sense of security in an unfamiliar hospital environment. It helps the child feel more at ease and can reduce anxiety and stress associated with hospitalization.
B. "You should begin to manipulate the infant's bedtime based on the hospital’s visiting hours." Disrupting the infant’s usual sleep routine can lead to increased stress and irritability. It is better to maintain familiar routines as much as possible to provide comfort and stability during the hospital stay.
C. "You should read the child a story about hospitalization." At 8 months, an infant may not comprehend stories about hospitalization. Reading stories is more effective for older children who can understand and process the information. The focus for infants should be on comfort and familiarity.
D. "You will need to go home when it is not visiting hours." Parents are typically encouraged to stay with their young children in the hospital whenever possible. Parental presence is crucial for the infant’s emotional well-being and can help reduce anxiety.
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