A nurse is caring for a child who has acute glomerulonephritis. Which of the following actions is the nurse's priority?
Maintain a saline-lock.
Check the child's day weight
Place the child on a no-salt-added diet.
Educate the parents about potential complications
The Correct Answer is B
A. Maintain a saline-lock:
Maintaining a saline lock is important for potential intravenous access, but it is not the most urgent priority compared to actions that directly monitor the child's condition and help manage the disease.
B. Check the child's daily weight:
Monitoring daily weight is crucial in acute glomerulonephritis, as it helps assess fluid balance and detect early signs of fluid retention or worsening kidney function, which are key concerns in this condition. This makes it a priority action.
C. Place the child on a no-salt-added diet:
While dietary modifications can be important for managing various health conditions, including kidney issues, this is not the top priority in this situation. Reducing salt intake can help manage fluid retention, but it is not the nurse's priority action at this moment.
D. Educate the parents about potential complications:
Patient education is crucial, especially in chronic conditions, but in this acute care scenario, the nurse's immediate priority is to address the child's needs. Educating parents about potential complications should be done, but it's not the most immediate action.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Position the child laterally
Explanation: When a child is experiencing a seizure, it's important to ensure their safety and prevent injury. Positioning the child laterally, also known as the recovery position, helps keep the airway clear and allows any fluids to drain from the mouth, reducing the risk of aspiration. It also helps prevent the child from choking on saliva or vomit.
The other options are not appropriate actions during a seizure:
B. Using a padded tongue blade is not recommended during a seizure. Placing objects in the mouth during a seizure can lead to injury, including damage to the teeth, jaw, or airway.
C. Attempting to stop the seizure is not within the nurse's control. Seizures are caused by abnormal electrical activity in the brain and should not be interrupted forcefully. Instead, the focus should be on ensuring the child's safety and managing the situation until the seizure stops on its own.
D. Restraining the child's arms is not advisable during a seizure. Restraining can cause harm and increase the risk of injury to the child or others involved. It's important to allow the seizure to run its course while protecting the child from harm.
Correct Answer is A
Explanation
Digoxin is a medication commonly used to treat certain heart conditions, including some congenital heart defects. It's important to monitor the heart rate and other signs of toxicity when administering digoxin, especially in pediatric patients. Let's break down the information given:
The pediatric maintenance dose of digoxin is 5 mcg/kg daily.
The child weighs 55 pounds (approximately 25 kg).
Given these values, the total daily dose for this child would be:
Total daily dose = 5 mcg/kg × 25 kg = 125 mcg
This total daily dose is usually given as a single dose. However, the child's heart rate is noted to be only 50 beats per minute (bpm). A heart rate of 50 bpm in a child could potentially indicate bradycardia (slow heart rate), which can be a sign of digoxin toxicity. Bradycardia is a known adverse effect of digoxin, and it's important to assess for other signs of toxicity as well, such as nausea, vomiting, and changes in color vision.
In this case, it would be prudent to withhold the digoxin and assess the child further for signs of toxicity or bradycardia. The dose should not be administered until the healthcare provider is consulted and appropriate action is determined.
So, the correct answer is indeed NO. Administering the digoxin without considering the slow heart rate and the potential for toxicity could be unsafe for the child.
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