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 C
Explanation
A. Supine: Lying on the back can limit lung expansion and is not the best position for a child with respiratory issues. It can contribute to atelectasis and does not facilitate effective breathing.
B. Prone: The prone position can improve oxygenation and ventilation, particularly in severe respiratory distress, but it may not be the most comfortable or practical for all patients, especially in a non-ICU setting.
C. Upright: Sitting upright or in a high Fowler's position is optimal for lung expansion. It facilitates easier breathing and helps the lungs expand more fully, allowing for better oxygenation.
D. Side-lying: Side-lying may be comfortable but does not provide as much benefit for lung expansion as the upright position. It is less effective in promoting maximal lung expansion compared to the upright position.
Correct Answer is A
Explanation
A. "Bend forward from the waist with your head and arms downward." This position, known as the Adam’s forward bend test, is commonly used to screen for scoliosis. It allows the nurse to observe for any asymmetry in the rib cage or spine, which could indicate scoliosis.
B. "Lie prone on the examination table." Lying prone (face down) does not allow for the assessment of spinal curvature or rib asymmetry. This position is not useful for scoliosis screening.
C. "Touch your chin to your chest, and then look up at the ceiling." These movements assess neck flexibility and range of motion, which are not relevant for screening scoliosis.
D. "Turn to the side, and remain in a relaxed position." Turning to the side and relaxing does not provide the necessary view of the spine to assess for scoliosis. This position does not allow for a clear view of any asymmetry in the spine or ribs.
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