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. Lime ice pop: A lime ice pop is a good option because it is cold, soothing, and less likely to irritate the throat or cause bleeding. The cold temperature can help reduce swelling and provide comfort. Additionally, it is not acidic or dairy-based, which makes it a safe choice.
B. Cranberry juice: Cranberry juice is acidic, which can irritate the throat and increase discomfort after a tonsillectomy. Acidic foods and drinks should be avoided during the recovery period to prevent irritation and pain.
C. Ice cream: While ice cream is cold and soothing, it contains dairy, which can increase mucus production. This may lead to discomfort and make swallowing more difficult post-surgery. It’s best to avoid dairy products immediately following a tonsillectomy.
D. Hot tea : Hot beverages should be avoided because they can cause vasodilation and increase the risk of postoperative bleeding. Cold or room temperature liquids are preferred to minimize discomfort and prevent complications.
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.
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