Which finding in a 5-year-old child diagnosed with hemolytic uremic syndrome would require the nurse to take immediate action?
BUN 14 mg/dL.
Serum Creatinine 0.4 mg/dL.
Urine output 76 mL/24 hours.
Hbg 12 g/dL.
The Correct Answer is C
Urine output 76 mL/24 hours.
Choice A rationale:
BUN (Blood Urea Nitrogen) of 14 mg/dL falls within the normal range (7-20 mg/dL) and is not an immediate concern.
Choice B rationale:
Serum Creatinine of 0.4 mg/dL is also within the normal range (0.2-0.5 mg/dL) and does not warrant immediate action.
Choice C rationale:
Urine output of 76 mL/24 hours is significantly decreased from the expected normal range (1-2 mL/kg/hour), indicating potential kidney dysfunction or dehydration. This requires immediate action to assess the child's hydration status and kidney function.
Choice D rationale:
Hb (Hemoglobin) of 12 g/dL is within the normal range for a 5-year-old child (11.5-15.5 g/dL) and does not necessitate urgent intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Remove all beverages from the patient's bedside.
Choice A rationale:
Giving the patient a laxative is inappropriate and unnecessary in the context of a ruptured appendix. The focus should be on preparing the patient for surgery and managing the acute condition.
Choice B rationale:
Administering ibuprofen should be avoided as it can mask symptoms and potentially worsen the patient's condition by masking signs of inflammation or infection. This delay in appropriate care could lead to complications.
Choice C rationale:
Removing all beverages from the patient's bedside is essential. NPO (nothing by mouth) status is typically maintained for patients with suspected appendicitis or other surgical conditions to prevent potential aspiration in case surgery is required.
Choice D rationale:
Providing a heating pad is contraindicated in cases of suspected appendicitis or any acute abdominal condition. Heat can worsen inflammation and potentially cause the appendix to rupture, leading to more severe complications.
Correct Answer is ["B","C"]
Explanation
Choice A rationale:
Hypoplastic left heart syndrome involves inadequate development of the left side of the heart, leading to systemic hypoperfusion. It is characterized by decreased pulmonary blood flow due to underdeveloped left heart structures.
Choice B rationale:
Tetralogy of Fallot is characterized by obstruction to blood flow, specifically pulmonary stenosis, which obstructs blood flow from the right ventricle to the pulmonary artery.
Choice C rationale:
Atrial Septal Defect (ASD) is a left-to-right shunt, leading to increased pulmonary blood flow. This occurs because oxygenated blood from the left atrium flows back into the right atrium and then into the pulmonary circulation.
Choice D rationale:
Aortic Stenosis is not correctly matched with its hemodynamic classification. Aortic stenosis involves obstruction to blood flow from the left ventricle to the aorta.
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